reglab/statecodes huggingface dataset:
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9358 - Reporting and disclosure requirements

(a) As specified below, every health insurance organization or issuer shall document and communicate information about its quality assessment program and quality improvement program, if it has one, and shall:
(1) Include a summary of its quality assessment and quality improvement programs in marketing materials;
(2) include a description of its quality assessment and quality improvement programs and a statement of patient rights and responsibilities with respect to those programs in the certificate of coverage or handbook provided to newly enrolled covered persons or enrollees, and
(3) make available once (1) every year to providers and covered persons or enrollees the findings from its quality assessment and quality improvement programs and information about its progress in meeting internal goals and external standards, where available. The reports shall include a description of the methods used to assess each specific area.
(b)
(1) A health insurance organization or issuer shall certify to the Commissioner annually that its quality assessment program and quality improvement program, along with the materials provided to providers and consumers in accordance with subsection (a) of this section, meet the requirements of this chapter.
(2) A health insurance organization or issuer shall make available for review by the public upon request, subject to a reasonable fee, the materials certified in clause (1) of this subsection, except for the materials subject to the confidentiality requirements of § 9359 of this title, and materials that are proprietary to the health plan. A health insurance organization or issuer shall retain all certified materials for at least three (3) years from the date the material has been used or until the material has been examined as part of a market conduct examination, whichever comes first.
History —Aug. 29, 2011, No. 194, added as § 20.080 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9359 - Confidentiality

(a) Data or information pertaining to the diagnosis, treatment or health of a covered person or enrollee is confidential and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of this chapter and as allowed by the laws of Puerto Rico and the United States of America; or upon the express consent of the covered person or enrollee; or pursuant to statute or court order for the production of evidence or the discovery thereof; or in the event of a claim or litigation between the covered person or enrollee and the health insurance organization or issuer. If any data or information pertaining to the diagnosis, treatment, or health of any existing or potential covered person or enrollee is disclosed pursuant to the provisions of this section, the health insurance organization or issuer shall not be liable for the disclosure or any subsequent use or misuse of the data. The health insurance organization or issuer shall be entitled to claim any statutory privileges against disclosure that the provider who furnished the information to the health issuer is entitled to claim.
(b) A person who, in good faith and without malice, takes an action or makes a decision or recommendation, or who furnishes any records, information, or assistance to a quality committee as a member, agent, or employee of a health insurance organization or issuer's quality committee in furtherance of the quality assessment or quality improvement activities of the health insurance organization or issuer, shall not be subject to liability for civil damages or any legal action in consequence of his/her action, nor shall the health insurance organization or issuer or any of its officers, directors, employees, or agents be liable for the activities of such person. This section shall not be construed to relieve any person of liability arising from treatment of a patient.
(c)
(1) The information considered by a quality committee and the records of its meetings shall be confidential and not subject to subpoena or order to produce, except in hearings held by the Commissioner. No member of a quality committee, or staff engaged in assisting or engaged in the quality assessment or quality improvement activities may be subpoenaed to testify in any judicial or quasi-judicial proceeding if the subpoena is based solely on these activities.
(d) To fulfill its obligations under this section, the health insurance organization or issuer shall have access to treatment records and other information pertaining to the diagnosis, treatment or health status of any covered person or enrollee.
History —Aug. 29, 2011, No. 194, added as § 20.090 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9360 - Contracting

Whenever a health insurance organization or issuer contracts to have another entity perform the quality assessment or quality improvement functions, the Commissioner shall hold the health insurance organization or issuer responsible for monitoring the activities of the entity with which it contracts.
History —Aug. 29, 2011, No. 194, added as § 20.100 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9391 - Title

This chapter shall be known and may be cited as the Health Insurance Organizations or Issuers Grievance Procedure. In the case of plans for private employers governed by the Employee Retirement Income Security Act of 1974, known as ERISA, any provision in this chapter found to be inconsistent with any federal law or regulation applicable to Puerto Rico regarding adverse determinations shall be understood to be amended to adjust to such law or regulation.
History —Aug. 29, 2011, No. 194, § 22.010, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 24, eff. 30 days after July 10, 2013.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9392 - Purpose

The purpose of this chapter is to provide standards for the establishment and maintenance of procedures by health insurance organizations and issuers to ensure that covered persons or enrollees have the opportunity for the appropriate resolution of grievances, as defined in this chapter.
History —Aug. 29, 2011, No. 194, § 22.020, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9394 - Applicability and scope

Except as otherwise specified, this chapter shall apply to all health insurance organizations or issuers.
None of the provisions of this chapter shall limit or in any way impair the legal powers of the Office of the Patient’s Advocate, the Medical Discipline and Licensure Board, or the Puerto Rico Health Insurance Administration to initiate, investigate, process, or adjudicate new or pending grievances. None of the provisions of this chapter shall be construed as an amendment or repeal of the laws, regulations, or procedures of the Office of the Patient’s Advocate, the Medical Discipline and Licensure Board, or the Puerto Rico Health Insurance Administration.
History —Aug. 29, 2011, No. 194, § 22.040, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 25, eff. 30 days after July 10, 2013.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9395 - Requirements to report grievances to the Commissioner

(a) Health insurance organizations or issuers shall maintain written records to document all grievances received during a calendar year (the register).
(b) A request for a first level review of a grievance involving an adverse determination shall be processed in compliance with § 9397 of this title. A request for a standard review of a grievance not involving an adverse determination shall be processed in compliance with § 9398 of this title.
(c) A request for an additional voluntary review of a grievance shall be processed in compliance with § 9399 of this title.
(d) For each grievance, the register shall contain at least the following information:
(1) A general description of the reason(s) for the grievance;
(2) the date received;
(3) the date of each review or, if applicable, review meeting;
(4) decision/resolution at each level of the grievance, if applicable;
(5) date of decision/resolution at each level, if applicable, and
(6) name of the covered person or enrollee for whom the grievance was filed.
(e) The register shall be maintained in a manner that is clear and accessible to the Commissioner.
(f)
(1) Health insurance organizations or issuers shall retain the register compiled for a calendar year for the longer of five (5) years or until the Commissioner has issued a final report of an examination that contains a review of the register for that calendar year.
(2)
(A) Health insurance organizations or issuers shall submit to the Commissioner, at least annually, a report in the format specified by him/her.
(B) The report shall include the following for each type of health plan offered by the health insurance organization or issuer:
(i) The certificate of compliance required by § 9396(c) of this title;
(ii) the number of covered persons or enrollees;
(iii) the total number of grievances;
(iv) the number of grievances for which a covered person or enrollee requested an additional voluntary grievance review pursuant to § 9399 of this title;
(v) the number of grievances resolved at each level, if applicable, and their decision/resolution;
(vi) the number of grievances appealed to the Commissioner of which the health insurance organization or issuer has been informed;
(vii) the number of grievances referred to alternative dispute resolution procedures, such as mediation or arbitration, or resulting in litigation, and
(viii) a synopsis of actions taken to correct the problems identified.
History —Aug. 29, 2011, No. 194, § 22.050, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9396 - Grievance review procedures

(a) Except as specified in § 9400 of this title, health insurance organizations or issuers shall receive and resolve grievances from covered persons or enrollees as provided in §§ 9397–9399 of this title.
(b) Health insurance organizations or issuers shall file a copy with the Commissioner of the procedures required under subsection (a) of this section, including all forms used to process the requests made. Any subsequent modifications to such procedures shall also be filed. The Commissioner may disapprove a filing received if it fails to comply with this chapter or the applicable regulations.
(c) In addition to the provisions of subsection (b) of this section, health insurance organizations or issuers shall file annually with the Commissioner, as part of the annual report required by § 9395 of this title, a certificate of compliance stating that such health insurance organizations or issuers have established and maintain, for each of their health plans, grievance procedures that fully comply with the provisions of this chapter.
(d) A description of the grievance procedures required under this section shall be included in the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage provided to covered persons or enrollees.
(e) The grievance procedure documents shall include a statement of a covered person or enrollee’s right to contact the Office of the Insurance Commissioner or the Office of the Patient’s Advocate for assistance at any time. The statement shall include the telephone number and address of the Office of the Insurance Commissioner and the Office of the Patient’s Advocate.
History —Aug. 29, 2011, No. 194, § 22.060, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 26, eff. 30 days after July 10, 2013.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9421 - Title

This chapter shall be known and may be cited as the chapter on Utilization Review and Benefit Determination.
History —Aug. 29, 2011, No. 194, added as § 24.010 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9422 - Purpose

This chapter establishes standards and criteria for the structure and operation of utilization review and benefit determination processes carried out by health insurance organizations or issuers. Its purpose is to facilitate ongoing assessment and management of healthcare services provided to covered persons or enrollees.
History —Aug. 29, 2011, No. 194, added as § 24.020 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9424 - Applicability and scope

This chapter shall apply to health insurance organizations or issuers offering a health plan that provides or performs utilization review services. The requirements of this chapter also shall apply to any designee of the health insurance organization or issuer or utilization review organization that performs utilization review functions on the health insurance organization or the issuer’s behalf.
History —Aug. 29, 2011, No. 194, added as § 24.040 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9425 - Corporate oversight of utilization review program

A health insurance organization or issuer shall be responsible for monitoring all utilization review activities carried out by, or on behalf of, the health insurance organization or issuer and for ensuring that all requirements of this chapter and the corresponding regulations are met. The health insurance organization or issuer also shall ensure that appropriate personnel have operational responsibility for the conduct of the health insurance organization or issuer's utilization review program.
History —Aug. 29, 2011, No. 194, added as § 24.050 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9426 - Contracting

Whenever a health insurance organization or issuer contracts to have a utilization review organization or other entity perform the utilization review functions required by this chapter, the Commissioner shall hold the health insurance organization or issuer liable for monitoring the activities of the utilization review organization or entity with which a contract was executed. The health insurance organization or issuer shall ensure that the requirements of this chapter and corresponding regulations are met.
History —Aug. 29, 2011, No. 194, added as § 24.060 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9427 - Scope and content of utilization review program

(a)
(1) A health insurance organization or issuer that requires a request for benefits under the covered person or enrollee’s health plan to be subjected to utilization review shall implement a written utilization review program that describes all review activities and procedures, both delegated and non-delegated for:
(A) The procedure to file benefit requests;
(B) the notification of utilization review and benefit determinations, and
(C) the adverse determinations review process in accordance with §§ 9391–9400 of this title.
(2) The program document shall describe the following:
(A) Procedures to evaluate the medical necessity, appropriateness, efficacy or efficiency of healthcare services;
(B) data sources and clinical review criteria used in decision-making process;
(C) mechanisms to ensure consistent application of clinical review criteria and compatible decisions;
(D) data collection processes and analytical methods used in assessing utilization of healthcare services;
(E) provisions for assuring confidentiality of clinical and proprietary information;
(F) the organizational structure (e.g. utilization review committee, quality assurance or other committee) that periodically assesses utilization review activities and reports to the health insurance organization or issuer’s governing body, and
(G) the position of the staff functionally responsible for day- to-day program management.
(b)
(1) Health insurance organizations or issuers shall file with the Commissioner, in the prescribed format, an annual report summarizing the activities of the utilization review program.
(2)
(A) In addition to the annual report summarizing the activities of the utilization review program, health insurance organizations or issuers shall keep, for a period of not less than six (6) years, records of all requests for benefits and claims and notifications related to the utilization review process.
(B) Health insurance organizations or issuers shall make the records mentioned in paragraph (A) of this clause available upon request to the Commissioner and any other regulatory agency.
History —Aug. 29, 2011, No. 194, added as § 24.070 on Aug. 23, 2012, No. 203, § 5, eff. 90 days Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9432 - Confidentiality requirements

Health insurance organizations or issuers shall annually certify to the Commissioner that their utilization review programs comply with all applicable Commonwealth and federal law establishing health information confidentiality requirements.
History —Aug. 29, 2011, No. 194, added as § 24.120 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9433 - Disclosure requirements

(a) A health insurance organization or issuer shall include a clear and comprehensive description of its utilization review and benefit determination procedures in the certificate of coverage or member handbook provided to covered persons or enrollees. The description shall include the procedures for obtaining review of adverse determinations, and a statement of rights and responsibilities of covered persons or enrollees with respect to those procedures.
(b) A health insurance organization or issuer shall include a summary of its utilization review and benefit determination procedures in materials intended for prospective covered persons or enrollees.
(c) A health insurance organization or issuer shall print on the health plan cards of the covered person or enrollee a toll-free telephone number to call for utilization review and benefit decisions.
History —Aug. 29, 2011, No. 194, added as § 24.130 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9434 - Rulemaking authority

The Commissioner may promulgate the necessary regulations to carryout the purposes of this chapter.
History —Aug. 29, 2011, No. 194, added as § 24.140 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9461 - Title

This chapter shall be known and may be cited as the chapter on Managed Care Plan Network Adequacy.
History —Aug. 29, 2011, No. 194, added as § 26.010 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9462 - Purpose

The purpose and intent of this chapter are to establish standards for the creation and maintenance of networks by health insurance organization or issuers and to assure the adequacy, accessibility and quality of healthcare services offered under a managed care plan. Requirements for contracts between health insurance organizations or issuers offering managed care plans and participating providers, particularly regarding the standards, terms, and provisions under which the participating provider will provide services to covered persons or enrollees are hereby established.
History —Aug. 29, 2011, No. 194, added as § 26.020 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9463 - Definitions

For purposes of this chapter:
(a) Intermediary.— Means a person authorized to negotiate and execute contracts with health insurance organizations or issuers on behalf of healthcare providers or a healthcare provider network.
(b) Primary care provider.— Means a participating provider in charge of supervising, coordinating or providing initial care or continuing care to a covered person or enrollee. In addition, the primary care provider may be required by the health insurance organization or issuer to initiate a referral for specialty care and maintain supervision of healthcare services rendered to the covered person or enrollee.
(c) Network.— Means the group of participating providers providing services to a managed care plan.
History —Aug. 29, 2011, No. 194, added as § 26.030 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9464 - Applicability and scope

This chapter shall apply to all health insurance organizations or issuers that offer managed care plans.
History —Aug. 29, 2011, No. 194, added as § 26.040 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9468 - Filing requirements and state administration

(a) Beginning on the effective date of this chapter, a health insurance organization or issuer shall file with the Commissioner sample contract forms proposed for use with its participating providers and intermediaries, so that the Commissioner may ascertain compliance with the provisions of this chapter.
(b) A health insurance organization or issuer shall submit material changes to a contract that would affect a provision required by this chapter or regulations thereunder to the Commissioner for approval sixty (60) days prior to use. For purposes of this subsection, changes in provider payment rates, coinsurance, copayments or deductibles, or other plan benefit modifications shall not be considered material changes.
(c) If the Commissioner takes no action within sixty (60) days after submission of a material change to a contract by a health insurance organization or issuer, the change is deemed approved.
(d) The health insurance organization or issuer shall maintain provider and intermediary contracts at its principal place of business in Puerto Rico, or in a readily accessible place.
History —Aug. 29, 2011, No. 194, added as § 26.080 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9469 - Contracting

(a) The execution of a contract shall not relieve the health insurance organization or issuer of its liability to any person with whom it has contracted for the provision or coverage of services, nor of its responsibility for compliance with the law or applicable regulations.
(b) All contracts shall be in writing and subject to review.
(c) All contracts shall meet the requirements of the applicable laws and regulations.
History —Aug. 29, 2011, No. 194, added as § 26.090 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9470 - Enforcement of this chapter

(a) If the Commissioner determines that a health insurance organization or issuer has not contracted with enough participating providers to assure that covered persons or enrollees have accessible healthcare services in a geographic area, or that a health insurance organization or issuer’s access plan does not assure reasonable access to covered benefits, or that a health insurance organization or issuer has entered into a contract that does not comply with this chapter, or that a health insurance organization or issuer has not complied with the provisions of this chapter, the Commissioner may institute a corrective action or may use any other powers under this Code or the Insurance Code of Puerto Rico to enforce compliance of the health insurance organization or issuer with this chapter.
(b) The Commissioner shall not act to arbitrate, mediate or settle disputes regarding a decision not to include a provider in a managed care plan or in a provider network or regarding any other dispute between a health insurance organization or issuer and a provider arising under or by reason of termination of a contract between them.
History —Aug. 29, 2011, No. 194, added as § 26.100 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9471 - Effective date

(a) All contracts between a health insurance organization or issuer and provider or intermediary in effect shall comply with this chapter not later than eighteen (18) months after the effective date of this chapter. The Commissioner may grant an extension of six (6) months, if the health insurance organization or issuer demonstrates good cause therefor.
(b) Any contract entered into or put in force on the effective date of this chapter shall comply with the provisions of this chapter.
History —Aug. 29, 2011, No. 194, added as § 26.140 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9501 - Title

This chapter shall be known and may be cited as the chapter on External Review.
History —Aug. 29, 2011, No. 194, added as § 28.010 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9502 - Purpose

The purpose of this chapter is to provide standards for the establishment and maintenance of external review procedures that shall govern in Puerto Rico, to assure that covered persons or enrollees have the opportunity for an independent review of an adverse determination or final adverse determination by health insurance organizations or issuers.
History —Aug. 29, 2011, No. 194, added as § 28.020 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9504 - Applicability and scope

(a) Except as provided in subsection (b) of this section, this chapter shall apply to all health insurance organizations or issuers.
(b) The provisions of this chapter shall not apply to a group or individual policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity, long-term care insurance, vision care or any other limited supplemental benefit or to a Medicare supplement policy of insurance, coverage under a plan through Medicare, Medicaid, or the federal employees health benefits program, any coverage issued under chapter 55 of Title 10, U.S. Code (medical and dental care for the members and former members of the uniformed services and their dependents) and any coverage issued as supplement to that coverage, any coverage issued as supplemental to liability insurance, workers' compensation or similar insurance, automobile medical-payment insurance or any insurance under which benefits are payable with or without regard to fault.
History —Aug. 29, 2011, No. 194, added as § 28.040 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9506 - Request for external review

(a) All requests for external review shall be made to the Commissioner or in accordance with the review process adopted by the health insurance organization or issuer in compliance with the applicable federal law. The Commissioner may provide the form and content of external review requests.
(b) A covered person or enrollee may make a request for an external review of an adverse determination or final adverse determination, in accordance with § 9505 of this title.
History —Aug. 29, 2011, No. 194, added as § 28.060 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9511 - Binding nature of external review decision

(a) An external review decision is binding on the health insurance organization or issuer except to the extent the health insurance organization or issuer has other remedies available under the applicable laws of Puerto Rico.
(b) An external review decision is binding on the covered person or enrollee, except to the extent the covered person or enrollee has other remedies available under the applicable laws of Puerto Rico or federal law.
(c) A covered person or enrollee may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision pursuant to this chapter.
History —Aug. 29, 2011, No. 194, added as § 28.110 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9514 - Hold harmless for independent review organizations

No independent review organization, clinical reviewer or an employee, agent or contractor of an independent review organization shall be liable in damages to any person for any opinions rendered or acts or omissions performed within the scope of their duties under this chapter, unless the opinion was rendered or act or omission performed in bad faith or involved gross negligence or noncompliance with the requirement to disclose any conflict of interests.
History —Aug. 29, 2011, No. 194, added as § 28.150 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9515 - External review reporting requirements

(a)
(1) Any independent review organization shall maintain written records of all external reviews it conducted during a calendar year and submit a report to the Commissioner, as required under clause (2) of this subsection. Such reports shall be made with respect to each health insurance organization or issuer individually and in the aggregate.
(2) Each independent review organization shall submit to the Commissioner at least once a year a report regarding the external reviews it conducted during the preceding calendar year in the format specified by the Commissioner.
(3) The report shall include the following information and for each health insurance organization or issuer specifically and in the aggregate:
(A) The total number of requests for external review;
(B) the number of requests for external review resolved and, of those resolved, the number resolved upholding and the number resolved reversing determinations;
(C) the average length of time for resolution;
(D) a summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the Commissioner;
(E) the number of external reviews that were terminated as a result of reconsideration by the health insurance organization or issuer after the receipt of additional information from the covered person or enrollee, and
(F) any other information the Commissioner may request or require.
(4) The independent review organization shall retain the written records required under this section for at least six (6) years.
(b)
(1) Each health insurance organization or issuer shall maintain written records, in the aggregate and for each type of health plan offered, on all requests for external review filed against them.
(2) Each health insurance organization or issuer shall submit to the Commissioner, upon request, a report on all requests for external review filed against them in the format specified by the Commissioner.
(3) The report shall include in the aggregate and specifically by each type of health plan:
(A) The total number of requests for external review.
(B) From the total number of requests for external review, the number of requests determined eligible for a full external review.
(C) Any other information the Commissioner may request or require.
(4) The health insurance organization or issuer shall retain the written records required under this section for at least six (6) years.
History —Aug. 29, 2011, No. 194, added as § 28.160 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9516 - Funding of external review

The health insurance organization or issuer against which a request for a standard external review or an expedited external review is filed shall be required to pay the independent review organization for conducting the external review.
The Office of the Insurance Commissioner shall notify health service organizations and issuers the costs of the process or any modification thereof within one hundred twenty (120) days in advance.
A covered person or enrollee shall pay not more than twenty-five dollars ($25) for each review. Provided, That the same covered person or enrollee shall not pay more than seventy-five dollars ($75) per policy year. The amount paid by the covered person or enrollee shall be reimbursed to him/her if a decision is made in his/her favor.
History —Aug. 29, 2011, No. 194, added as § 28.170 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9517 - Disclosure requirements

(a)
(1) Each health insurance organization or issuer shall include a description of the external review procedures in the policy, certificate, membership booklet, outline of coverage. or other evidence of coverage it provides to covered persons or enrollees.
(2) The disclosure of external review procedures required by clause (1) of this subsection shall be in a format prescribed by the Commissioner.
(b) The description of external review procedures shall include a statement that informs the covered person or enrollee of his/her right to file a request for an external review of an adverse determination or final adverse determination with the Commissioner. The statement may explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, healthcare setting, level of care, or effectiveness of service or rescission of coverage. The statement shall include the telephone number and address of the Commissioner.
(c) In addition to the provisions of subsection (b) of this Section, the statement shall inform the covered person or enrollee that, when filing a request for an external review, he/she will be required to authorize the release of any medical information that may be required or necessary to be reviewed for the purpose of reaching a decision on the external review.
History —Aug. 29, 2011, No. 194, added as § 28.180 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 150 - Off-label Use (§§ 9981 — 9984) › § 9981 - Purpose

The purpose of this chapter is to establish standards for the payment or reimbursement of costs associated with prescription drugs that, even though they have been approved by the U. S. Food and Drug Administration (FDA), are used for indications other than those stated in the labeling approved by the FDA (this use is hereinafter referred to as “off-label use”). Denial of payment or reimbursement for off-label use can interrupt or effectively deny access to necessary and appropriate treatment for covered persons or enrollees.
History —Aug. 29, 2011, No. 194, added as § 52.010 on Aug. 23, 2012, No. 203, § 8, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 150 - Off-label Use (§§ 9981 — 9984) › § 9982 - Applicability and scope

This chapter shall apply to all health plans that are issued, amended, delivered or renewed on or after the effective date of this chapter and provide coverage for drugs. It also shall apply to all persons making determinations regarding payment of reimbursement for prescription drugs under these health plans.
History —Aug. 29, 2011, No. 194, added as § 52.020 on Aug. 23, 2012, No. 203, § 8, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 150 - Off-label Use (§§ 9981 — 9984) › § 9983 - Definitions

(a) Standard reference compendia.— Means:
(1) The American Hospital Formulary Service-Drug Information;
(2) The American Medical Association Drug Evaluation; or
(3) The United States Pharmacopoeia-Drug Information.
(b) FDA.— Means the United States Food and Drug Administration.
(c) Peer-reviewed medical literature.— Means a published scientific study in a journal or other publication in which original manuscripts have been published only after having been critically reviewed by unbiased independent experts, and that has been determined by the International Committee of Medical Journal Editors to have met the Uniform Requirements for Manuscripts submitted to biomedical journals. Peer-reviewed medical literature does not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or a health insurance organization or issuer.
(d) Drug or Drugs.— Means any substance prescribed by a licensed healthcare provider that is intended for use in the diagnosis, mitigation, treatment or prevention of disease that is taken (by mouth; injected into a muscle, the skin, a blood vessel or cavity of the body; applied to the skin; or otherwise assimilated by the body). The term includes only those substances that are approved by the FDA for at least one indication.
History —Aug. 29, 2011, No. 194, added as § 52.030 on Aug. 23, 2012, No. 203, § 8, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 150 - Off-label Use (§§ 9981 — 9984) › § 9984 - Standards of coverage

(a) A health plan that provides coverage for drugs shall provide for the dispensation of any drug covered, regardless of the disorder, injury, illness, condition, or disease for which they were prescribed, provided, that:
(1) The drug has been approved by the FDA for at least one indication, and
(2) the drug is recognized for treatment of the disorder, injury, illness, condition, or disease in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature.
(b) Coverage of a drug pursuant to this section shall also include medically necessary services associated with the administration of the drug.
(c) This section shall not be construed to require a health insurance organization or issuer to provide coverage for a drug when the FDA has determined its use to be contra-indicated for treatment of the current indication.
(d) The following drugs or services shall not be subject to coverage under subsection (a) of this section:
(1) Drugs that are used in research trials sponsored by their manufacturers or a government entity, or
(2) drugs or services furnished in a research trial, if the sponsor of the research trial furnishes the drugs or services without charge to any participant in the research trial.
History —Aug. 29, 2011, No. 194, added as § 52.040 on Aug. 23, 2012, No. 203, § 8, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026) › § 10021 - Title

This chapter shall be known and may be cited as the chapter on Coverage for Newborn and Newly Adopted Children and Children Placed for Adoption.
History —Aug. 29, 2011, No. 194, § 54.010, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026) › § 10022 - Purpose

The purpose of this chapter is to provide for uniformity of coverage requirements for newborn and newly adopted children and children placed for adoption under both group and individual health plans.
History —Aug. 29, 2011, No. 194, § 54.020, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026) › § 10023 - Definitions

For purposes of this chapter:
(a) Health plan.— Means a policy, contract, certificate, or agreement offered or issued by a health insurance organization or issuer to provide, deliver, arrange for healthcare service or pay for or reimburse the costs thereof.
History —Aug. 29, 2011, No. 194, § 54.030, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026) › § 10024 - Applicability

(a) Except as provided in subsection (b) of this section, this chapter shall apply to health plans that provide coverage for a dependent of a covered person or enrollee.
(b) The provisions of this chapter shall not apply to a group or individual health plan that provides coverage only for a specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity or other fixed indemnity coverage, vision care or any other supplemental benefit or a Medicare supplement policy, coverage under a plan through Medicare, Medicaid or the federal employees health benefits program, any coverage issued as supplemental to liability insurance, workers' compensation or similar insurance, automobile medical-payment insurance or any insurance under which benefits are payable with or without regard to fault.
History —Aug. 29, 2011, No. 194, § 54.040, eff. 180 days after Aug. 29, 2011.