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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9272 - Definitions

For purposes of this chapter:
(a) Evidence of coverage.— Means a certificate, policy, agreement, or contract setting forth the coverage to which a subscriber is entitled.
(b) Limited health service organization.— Means any corporation, partnership or other entity that undertakes to provide or arrange for the provision of one (1) or more limited health services to subscribers in return for a prepayment which is deemed to be earned whether the individual uses the limited health services provided under the plan. Limited health service organization does not include:
(1) An entity that meets the requirements of § 9277 of this title, or
(2) a provider or entity when providing or arranging for the provision of limited health services pursuant to a contract with a limited health service organization or with an entity that complies with the provisions of clause (1) of this subsection.
(c) Provider.— Means a physician, dentist, hospital, healthcare facility, or other person or institution duly authorized in Puerto Rico to deliver or furnish limited health services.
(d) Limited health services.— Means dental care services, vision care services, mental health services, substance abuse services, pharmaceutical services, podiatric care services, and such other services as may be determined by the Commissioner to be limited health services. Limited health service shall not include hospital, medical, surgical or emergency services except as these services are provided incident to the limited health services set forth in the preceding sentence.
(e) Subscriber.— Means any person, including his/her dependents, who is entitled to received limited health services pursuant to a contract with an entity authorized to provide or arrange for such services.
History —Aug. 29, 2011, No. 194, added as § 16.020 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9273 - Certificate of authority required

No person, corporation, partnership, or entity may operate a limited health service organization in Puerto Rico without obtaining a certificate of authority therefor from the Commissioner.
History —Aug. 29, 2011, No. 194, added as § 16.030 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9275 - Issuance or denial of certificate of authority

(a) The Commissioner shall issue or deny a certificate of authority to any applicant that files an application pursuant to § 9274 of this title. The Commissioner shall issue a certificate of authority provided that the following conditions are met:
(1) The requirements of § 9274 of this title have been fulfilled.
(2) The individuals responsible for conducting the applicant's affairs are competent, trustworthy, and possess good reputations, and have had appropriate experience, training, or education.
(3) The applicant is financially sound. In making this determination, the Commissioner may consider:
(A) The financial soundness of the applicant's arrangements for the provision of limited health services, and the minimum standard rates, deductibles, copayments, and other patient charges used in connection therewith;
(B) the adequacy of working capital, other sources of funding, and provisions for contingencies;
(C) any agreement for paying the cost of the limited health services or for alternative coverage in the event of insolvency of the limited health service organization, and
(D) the manner in which the requirements of § 9288 of this title will be fulfilled.
(4) The agreements with providers for the provision of limited health services contain the provisions required by § 9287 of this title.
(5) Any deficiencies identified by the Commissioner have been corrected.
(b) If the certificate of authority is denied, the Commissioner shall notify the applicant and shall specify the reasons for denial in the notice. The applicant shall have twenty (20) days from the date of receipt of the notice to request a hearing before the Commissioner.
History —Aug. 29, 2011, No. 194, added as § 16.050 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9276 - Effect on organizations operating on effective date of this chapter

Within ninety (90) days after the effective date of this chapter, every limited health service organization operating in Puerto Rico without a certificate of authority shall submit an application for a certificate of authority to the Commissioner pursuant to the provisions of § 9274 of this title. Such organization may continue to operate during the pendency of its application. In the event an application is denied, the applicant will then be treated as a limited health service organization whose certificate of authority has been revoked.
History —Aug. 29, 2011, No. 194, added as § 16.060 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9277 - Filing requirements for authorized entities

(a) A health service organization, a disability insurance company, a nonprofit health, hospital or medical service organization, or a fraternal benefit society may file for approval with the Commissioner a request to offer limited health services by submitting the information described in subsections (d), (e), (g), (h), (j), (k), (l), and (o) of § 9274 of this title and any additional document that the Commissioner may request.
(b) If the Commissioner disapproves the filing, the procedures set forth in § 9275(b) of this title shall be followed.
History —Aug. 29, 2011, No. 194, added as § 16.070 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9278 - Changes and material modifications; addition of limited health services

(a) A limited health service organization shall file with the Commissioner prior to use, a notice of any intended change in rates, charges, or benefits and of any material modification of operations or information furnished pursuant to § 9274 of this title. Such filing shall be made within sixty (60) days before the change. Once the sixty (60)-day term elapses, the change shall be deemed to be approved, unless it is expressly approved or disapproved by order of the Commissioner. The Commissioner may, upon previous notification, extend such term for sixty (60) additional days, within which he/she may approve or disapprove the change.
(b) If a limited health service organization desires to provide additional limited health services, it shall file a notice with the Commissioner and, at the same time, shall submit the information required by § 9274 of this title and shall comply with §§ 9287, 9288 and 9294 of this title.
(c) If such filings are denied, the procedure set forth in § 9275(b) of this title shall be followed.
History —Aug. 29, 2011, No. 194, added as § 16.080 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9280 - Rates and charges

(a) The rates for a limited health service plan to be used by a limited health service organization shall be filed with the Commissioner, before applying them in Puerto Rico. No filing shall be effective until sixty (60) days after the receipt thereof in the Office of the Commissioner, unless it is expressly approved by the Commissioner. The Commissioner may extend such period for an additional term that shall not exceed sixty (60) days, if the Commissioner notifies the applicant within such waiting period. If the Commissioner determines that the information provided in the filing is not sufficient and, therefore, requires additional information, the period of time from the notification of the Commissioner of such requirement to the receipt of the requested information by the Commissioner shall not be counted for purposes of computing the aforementioned terms. To determine whether a rate is approved or disapproved, the Commissioner may require the submittal of any relevant information that he/she may deem pertinent.
(b) Rates shall be established in accordance with the actuarial principles for various categories of subscribers. Charges applicable to a subscriber shall not be individually determined based on health status. Rates shall not be excessive, inadequate, or discriminatory. A certification by a qualified actuary, to the appropriateness of the rates, based on reasonable assumptions shall be enclosed with the filing, along with adequate supporting information.
(c) If the Commissioner disapproves the filing, the Commissioner shall notify the applicant and shall specify the reasons for disapproval. The affected party shall have twenty (20) days from the date of receipt of the notice to request a hearing.
Any time after the applicable review period as provided in subsection (a) of this section, the Commissioner may hold a hearing to determine whether the filing meets the established requirements. The Commissioner shall provide a notice in writing to the limited health service organization that made the filing at least ten (10) days before the hearing. If, after the hearing, the Commissioner determines that the filing does not meet the requirements of this Section, he/she shall enter an order specifying the reasons for disapproval and the date, within a reasonable subsequent period, on which the filing shall be deemed to be ineffective. Such order shall not affect any agreement executed or ratified before the expiration of the term specified in the order.
History —Aug. 29, 2011, No. 194, added as § 16.100 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9281 - Construction with other laws

(a)
(1) A limited health service organization organized under the laws of Puerto Rico shall be deemed to be a domestic insurer for purposes of insurance holding companies regulations, unless specifically exempted in writing from one (1) or more of the provisions of such regulations by the Commissioner.
(2) A limited health service organization shall be subject to the provisions of §§ 2701 et seq. of this title.
(b) The provision of limited health services by a limited health service organization shall not be deemed to be the practice of medicine or other healing arts.
History —Aug. 29, 2011, No. 194, added as § 16.110 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9282 - Nonduplication of coverage

A limited health service organization, health service organization, disability insurance company, nonprofit health, hospital or medical service organizations may exclude, in any contract or policy, any coverage that would duplicate the coverage for limited health services.
History —Aug. 29, 2011, No. 194, added as § 16.120 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9283 - Grievance system

Every limited health service organization shall establish and maintain a grievance system as provided in §§ 9391 et seq. and 9501 of this title, which shall be approved by the Commissioner and provide reasonable procedures for resolving written grievances initiated by subscribers and providers related to the provisions of the limited health service plan. Nothing herein shall be construed to preclude a subscriber or a provider from filing a grievance with the Commissioner or as limiting the Commissioner's ability to investigate such grievances.
History —Aug. 29, 2011, No. 194, added as § 16.130 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9284 - Examination

(a) The Commissioner may examine the affairs of any limited health service organization and providers with which such organization maintains contracts, agreements or other arrangements, at least every three (3) years.
(b) Every limited health service organization and provider shall make its relevant books and records available for an examination and in every way cooperate with the Commissioner to facilitate an examination. For examination purposes, the Commissioner may administer oaths and examine the officials and agents of the organization and of the providers.
(c) The reasonable expenses of an examination under this section shall be charged to the organization being examined and remitted to the Commissioner.
(d) In the case of foreign limited health service organizations, the Commissioner may accept the report of an examination made by the Commissioner of the organization's state of domicile.
History —Aug. 29, 2011, No. 194, added as § 16.140 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9285 - Investments

The funds of a limited health service organization shall be invested only in securities and other investments allowed by the laws of Puerto Rico for the investment of assets that constitute the legal reserve of life issuers or other securities or investments that the Commissioner may allow.
History —Aug. 29, 2011, No. 194, added as § 16.150 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9286 - Authorized representatives

(a) No limited health service organization shall engage in procurement and underwriting activities, if not by an authorized representative of such organization.
(b) The provisions related to licensing, commissions, requirements, examination, controlled businesses, bonds, summons, books, documents, and reports of §§ 949 et seq. of this title shall apply to limited health service organizations intermediaries.
History —Aug. 29, 2011, No. 194, added as § 16.160 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9287 - Contracts with providers

All contracts with providers for the provision of limited health services to subscribers shall contain the following terms and conditions:
(a) In the event the limited health service organization fails to pay a provider for rendering services to a subscriber, including insolvency or breach of contract or any other reason, the subscribers shall not be liable to the contracted provider for any sums owed.
(b) No provider, agent, trustee, or assignee thereof may initiate an action at law or attempt to collect from the subscriber sums owed to the provider by the limited health service organization.
(c) These provisions do not prohibit collection of charges not covered by the limited health service organization to the subscriber such as copayments, deductibles, or coinsurance, provided that it has been agreed upon in the contract or policy between the limited health service organization and the subscriber.
(d) The provisions of this section shall remain in effect regardless of the termination of a contract between the limited health service organization and the subscriber and the reasons for such termination.
(e) Termination of the contract between the limited health service organization and the provider shall not exempt the provider from completing procedures in progress on subscribers then receiving treatment for a specific condition for a period not to exceed thirty (30) days, subject to the same copayment or other applicable charge in effect upon the effective date of termination of the contract. This period of time shall only apply in those cases in which a transition period for the continuation of services for subscribers as a result of the termination of a contract between the limited health service organization and the provider has not been provided under federal or Commonwealth law.
History —Aug. 29, 2011, No. 194, added as § 16.170 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9288 - Protection against insolvency; deposit

(a) Except as approved in accordance with subsection (d) of this section, each limited health service organization shall at all times have and maintain tangible net equity equal to the greater of fifty thousand dollars ($50,000); or two percent (2%) of the organization's annual gross premium income.
(b) For purposes of this section, “net equity” means the excess of total assets over total liabilities, excluding liabilities which have been subordinated in a manner acceptable to the Commissioner. “Tangible net equity” means equity reduced by the value assigned to intangible assets including, but not limited to, goodwill; going concern value; organizational expense; starting-up costs; long-term prepayments of deferred charges; nonreturnable deposits; and obligations of officers, directors, owners, or affiliates, except short-term obligations of affiliates for goods or services arising in the normal course of business that are payable on the same terms as equivalent transactions with nonaffiliates and that are not past due.
(c)
(1) At the time of approval, each limited health service organization shall deposit with the Commissioner assets eligible for deposit in the amount of six hundred thousand dollars ($600,000), as provided in § 802 of this title.
(2) The deposit shall be an admitted asset of the limited health service organization in the determination of tangible net equity.
(3) All income from deposits shall be an asset of the limited health service organization. A limited health service organization may withdraw a deposit or any part thereof after making a substitute deposit of equal amount and value. Any securities shall be approved by the Commissioner before being substituted.
(4) The deposit shall be used to protect the interests of subscribers and to assure continuation of limited healthcare services to subscribers of a limited health service organization that is in rehabilitation. If a limited health service organization is placed in receivership or liquidation, the deposit shall be an asset subject to provisions applicable to a liquidation process.
(d) Upon application by a limited health service organization, the Commissioner may waive some or all of the requirements of subsection (a) of this section for any period of time the Commissioner deems proper if the limited health service organization has a net equity of at least five million dollars ($5,000,000).
History —Aug. 29, 2011, No. 194, added as § 16.180 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9289 - Officers and employees fidelity bond

(a) A limited health service organization shall maintain in force a fidelity bond in its own name on its officers and employees in an amount not less than fifty thousand dollars ($50,000) or in any other amount prescribed by the Commissioner.
(b) In lieu of the bond requirement, a limited health service organization may deposit with the Commissioner cash, securities or other investments of the types set forth in § 9285 of this title. Such deposit shall be in the amount required for a bond.
History —Aug. 29, 2011, No. 194, added as § 16.190 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9290 - Annual reports

(a) Every limited health service organization shall file with the Commissioner, on or before March 31 of each year, an exact report covering the preceding calendar year, certified by a certified public accountant and signed under oath by two (2) principal officers.
(b) The report shall be on forms prescribed by the Commissioner and shall include:
(1) A financial statement of the organization, including its balance sheet, income and loss statement, and a statement of sources and application of funds for the preceding year;
(2) the number of subscribers at the beginning of the year, the number of subscribers as of the end of the year, and the number of enrollments terminated during the year;
(3) any material change to the information submitted in accordance with § 9274 of this title, and
(4) such other information related to the performance of the organization as is necessary to enable the Commissioner to carry out his/her duties under this chapter.
(c) The Commissioner may require more frequent reports containing such information as is necessary to enable the Commissioner to carry out his/her duties under this chapter.
(d) The Commissioner may assess a fine of up to one hundred dollars ($100) per day for each day any required report is late, and suspend the organization's certificate of authority pending the proper filing of the required report by the organization.
History —Aug. 29, 2011, No. 194, added as § 16.200 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9291 - Suspension or revocation of certificate of authority

(a) The Commissioner may suspend or revoke the certificate of authority issued to a limited health service organization pursuant to this chapter upon determining that any of the following conditions exist:
(1) The limited health service organization is operating significantly in contravention of its basic organizational document;
(2) the limited health service organization issues an evidence of coverage or uses rates or charges that do not meet the requirements of §§ 9279 and 9280 of this title;
(3) the limited health service organization is unable to fulfill its obligations to furnish limited health services;
(4) the limited health service organization is not financially sound and may reasonably be expected to be unable to meet its obligations to subscribers or prospective subscribers;
(5) the tangible net equity of the limited health service organization is less than required under § 9288 of this title, or such organization has failed to correct any deficiency in its tangible net equity as required by the Commissioner;
(6) the limited health service organization has failed to implement in a reasonable manner the grievance system required under § 9283 of this title;
(7) the continued operation of the limited health service organization would be hazardous to its subscribers;
(8) the limited health service organization has otherwise failed to comply with this Code, the Insurance Code of Puerto Rico, rule, regulation, or lawful order of the Commissioner, or
(9) the organization or any person acting on its behalf has advertised or marketed its services in a deceitful, unfair, or misleading manner.
(b) If the Commissioner has cause to believe that grounds for the suspension or revocation of a certificate of authority exist, he/she shall notify the limited health service organization in writing specifically stating the grounds for suspension or revocation and fixing the date not more than thirty (30) days thereafter for a hearing.
(c) When the certificate of authority of a limited health service organization is revoked, the organization shall proceed immediately to wind up its affairs, and shall conduct no further business except as may be essential to the orderly cease of operations. It shall engage in no further advertising or solicitation whatsoever. The Commissioner may, by written order, permit such further operation of the organization as he/she may find to be in the best interest of subscribers, to the end that subscribers will be afforded the greatest practical opportunity to obtain continuing limited health services.
History —Aug. 29, 2011, No. 194, added as § 16.210 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9292 - Additional sanctions for violations

In addition to the suspension or revocation of the certificate of authority or in lieu of such penalty, a limited health service organization which has violated any provision of this Code, the Insurance Code of Puerto Rico, rule, regulation, or lawful order of the Commissioner, may be imposed the sanctions or penalties prescribed for issuers.
History —Aug. 29, 2011, No. 194, added as § 16.220 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9293 - Rehabilitation or liquidation

(a) Any rehabilitation or liquidation of a limited health service organization shall be deemed to be the rehabilitation or liquidation of an issuer and shall be conducted under the supervision of the Commissioner by virtue of the Insurance Code of Puerto Rico on rehabilitation or liquidation. The Commissioner may request the court to enter an order for rehabilitation, liquidation or any other applicable remedy, or when in his/her judgment the continued operation of the organization would be hazardous to its subscribers or the public interest.
(b) A limited health service organization shall not be subject to the laws and regulations governing insurance insolvency guaranty funds, nor shall any insurance insolvency guaranty fund provide protection to individuals entitled to receive limited health services from a limited health service organization.
History —Aug. 29, 2011, No. 194, added as § 16.230 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9294 - Filing fees

Every limited health service organization shall pay to the Commissioner the established fees for the following:
(a) For filing an application for a certificate of authority or amendment thereto;
(b) for filing a material modification of or an addition to a limited health service;
(c) for filing each annual report, and
(d) for filing periodic reports as required by the Commissioner.
History —Aug. 29, 2011, No. 194, added as § 16.240 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9295 - Confidentiality

(a) Any information obtained by a limited health service organization from the subscriber or a provider pertaining to the diagnosis, treatment or health of the subscriber shall be deemed confidential and shall not be disclosed to any person except:
(1) To the extent that it may be necessary to carry out the purposes of this chapter;
(2) upon the express consent of the subscriber or provider, as appropriate;
(3) pursuant to a statute or court order for the production of evidence or the discovery thereof, or
(4) in the event of claim or litigation wherein the data or information is relevant.
(b) A limited health service organization shall be entitled to claim any statutory privileges against disclosure that a provider is entitled to claim with respect to any information pertaining to the diagnosis, treatment, and health of any subscriber or applicant.
(c) In addition, any information provided to the Commissioner that constitutes a trade secret, or privileged information, or is part of an investigation shall be deemed to be confidential.
History —Aug. 29, 2011, No. 194, added as § 16.250 on Aug. 23, 2012, No. 203, § 2, 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 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9296 - Taxes

The same taxes provided for health service organizations shall be imposed upon each limited health service organization. Such organizations shall be entitled to the same tax deductions, reductions, and credits that health service organizations are entitled to receive.
History —Aug. 29, 2011, No. 194, added as § 16.260 on Aug. 23, 2012, No. 203, § 2, 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 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9321 - Title

This chapter shall be known and may be cited as the chapter on Healthcare Professionals or Entities Credentialing Verification.
History —Aug. 29, 2011, No. 194, added as § 18.010 on Aug. 23, 2012, No. 203, § 3, 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 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9322 - Purpose

The purpose of this chapter is to require health insurance organizations or issuers to establish a comprehensive healthcare professional or entity credentialing verification program to ensure that participating healthcare professionals meet specific minimum standards of professional or licensing qualifications. The standards set out in this chapter address the initial credentialing verification and subsequent re-credentialing thereof.
History —Aug. 29, 2011, No. 194, added as § 18.020 on Aug. 23, 2012, No. 203, § 3, 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 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9323 - Definitions

For purposes of this chapter:
(a) Credentialing verification.— Is the process of obtaining and verifying information about a healthcare professional or entity, and evaluating that healthcare professional or entity, when such healthcare professional or entity applies to become a participating provider in a managed care plan offered by a health insurance organization or issuer.
(b) Primary verification.— Means verification by the health insurance organization or issuer of a healthcare professional or entity's credentials based upon evidence obtained directly from the issuing source of the credential.
(c) Secondary verification.— Means verification by the health insurance organization or issuer of a healthcare professional's credentials based upon evidence obtained by means other than direct contact with the issuing source of the credential (e.g., copies of certificates provided by the applying healthcare professional).
History —Aug. 29, 2011, No. 194, added as § 18.030 on Aug. 23, 2012, No. 203, § 3, 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 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9324 - Applicability and scope

This chapter shall apply to health insurance organizations or issuers that offer managed care plans.
History —Aug. 29, 2011, No. 194, added as § 18.040 on Aug. 23, 2012, No. 203, § 3, 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 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9325 - General responsibilities of health insurance organizations or issuers

(a) A health insurance organization or issuer shall:
(1) Establish written policies and procedures for credentialing verification of all healthcare professionals or entities with which the health insurance organization or issuer contracts and apply these standards consistently;
(2) verify the credentials of a healthcare professional or entity before entering into a contract with the same. The medical director of the health insurance organization or issuer or other designated healthcare professional shall have responsibility for, and shall participate in, healthcare professional credentialing verification;
(3) establish a credentialing verification committee consisting of licensed physicians and other healthcare professionals to review credentialing verification information and supporting documents and make decisions regarding credentialing verification;
(4) make available for review by the applying healthcare professional upon written request all application and credentialing verification policies and procedures;
(5) retain all records and documents relating to a healthcare professional's credentialing verification process for at least three (3) years, and
(6) keep confidential all information obtained in the credentialing verification process, except as otherwise provided by law.
(b) Nothing in this chapter shall be construed to require a health insurance organization or issuer to enter into contract with a provider as a participating provider solely because the provider meets the health insurance organization or issuer's credentialing verification standards, or to prevent a health insurance organization or issuer from utilizing additional criteria in selecting the healthcare professionals with whom it contracts.
History —Aug. 29, 2011, No. 194, added as § 18.050 on Aug. 23, 2012, No. 203, § 3, 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 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9326 - Verification responsibilities of health insurance organizations or issuers

A health insurance organization or issuer shall:
(a) Obtain primary verification of at least the following information about the applicant:
(1) Current license, certificate of authority or registration to practice his/her profession in Puerto Rico;
(2) meets financial responsibility requirements;
(3) status of hospital privileges (if applicable);
(4) specialty board certification status (if applicable);
(5) current Drug Enforcement Agency (DEA) registration certificate (if applicable);
(6) graduation from an accredited professional school, and
(7) completion of post graduate training (if applicable).
(b) Obtain, subject to either primary or secondary verification at the health insurance organization or issuer's discretion:
(1) The healthcare professional's license history in Puerto Rico and all other states;
(2) the healthcare professional's malpractice history, and
(3) the healthcare professional's practice history.
(c) At least every three (3) years, obtain primary verification of a participating healthcare professional's:
(1) Current license, certificate of authority or registration to practice his/her profession in Puerto Rico;
(2) meets financial responsibility requirements;
(3) status of hospital privileges (if applicable);
(4) current DEA registration certificate (if applicable), and
(5) specialty board certification status (if applicable).
(d) Require all participating providers to notify the health insurance organization or issuer of changes in the status of any of the items listed in this section and indicate to the participating providers the contact information to report such changes.
History —Aug. 29, 2011, No. 194, added as § 18.060 on Aug. 23, 2012, No. 203, § 3, 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 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9327 - Healthcare professional's right to review credentialing verification information

A health insurance organization or issuer shall provide a healthcare professional or entity the opportunity to review and correct information submitted in support of his/her credentialing verification application as set forth below.
(a) Each healthcare professional or entity that is subject to the credentialing verification process shall have the right to review all information, including the source of that information, obtained by the health insurance organization or issuer during the credentialing process.
(b) A health insurance organization or issuer shall notify a healthcare professional of any information obtained that does not meet its credentialing verification standards or that varies substantially from the information provided by the healthcare professional or entity. Notwithstanding the foregoing, the health insurance organization or issuer shall not be required to reveal the source of information, if such disclosure is prohibited by law.
(c) A healthcare professional or entity shall have the right to correct any erroneous information. A health insurance organization or issuer shall have a formal process whereby a healthcare professional or entity may submit supplemental or corrected information to the credentialing verification committee and request reconsideration, if the healthcare professional or entity believes that the committee has received information that is incorrect, misleading or erroneous. Supplemental information shall be subject to confirmation by the health insurance organization or issuer.
History —Aug. 29, 2011, No. 194, added as § 18.070 on Aug. 23, 2012, No. 203, § 3, 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 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9328 - Contracting

Whenever a health insurance organization or issuer contracts to have another entity perform the credentialing functions required by this chapter, 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 § 18.080 on Aug. 23, 2012, No. 203, § 3, 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) › § 9351 - Title

This chapter shall be known and may be cited as the Health Insurance Organization or Issuer Quality Assessment and Improvement.
History —Aug. 29, 2011, No. 194, added as § 20.010 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) › § 9352 - Purpose

This chapter establishes criteria for the quality assessment and quality improvement activities of all health insurance organizations or issuers that offer managed care plans. The purpose of establishing such criteria is to enable health insurance organizations or issuers to evaluate, maintain and improve the quality of healthcare services provided to covered person or enrollee or enrollees.
History —Aug. 29, 2011, No. 194, added as § 20.020 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) › § 9353 - Definitions

(a) Consumer.— Means someone in the general public who may or may not be a covered person or enrollee or enrollee or a purchaser of healthcare services, including employers.
(b) Quality assessment.— Means the measurement and evaluation of the quality and outcomes of medical care provided to individuals, groups or populations.
(c) Quality improvement.— Means the effort to improve the processes and outcomes related to the provision of healthcare services within the health plan.
History —Aug. 29, 2011, No. 194, added as § 20.030 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) › § 9354 - Applicability and scope

Except as otherwise specified, this chapter shall apply to all health insurance organizations or issuers that offer managed care plans.
History —Aug. 29, 2011, No. 194, added as § 20.040 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) › § 9355 - Quality assessment standards

Any health insurance organization or issuer that provides managed care plans shall develop and maintain the infrastructure and disclosure systems necessary to measure the quality of healthcare services provided to covered person or enrollees or enrollees on a regular basis and appropriate to the types of plans offered by it. For such purposes, a health insurance organization or issuer shall:
(a) Establish a system designed to assess the quality of healthcare services provided to covered person or enrollees or enrollees. Such system shall be appropriate to the types of plans offered by the health insurance organization or issuer.
(b) Communicate the findings of the quality assessment and improvement program in a timely manner to applicable regulatory agencies, including the Commissioner, providers and consumers, as provided in § 9358 of this title.
(c) Report to the applicable regulatory agencies, including the Commissioner, any persistent pattern of problematic care provided by a provider that is sufficient to cause the health insurance organization or issuer to terminate or suspend contractual arrangements with such provider. A health insurance organization or issuer shall not be held liable, for complying with the duties imposed onto it by this provision.
(d) File with the Commissioner in the prescribed format a description of the quality assessment program, which shall include a signed certification by a corporate officer of the health insurance organization or issuer that the filing meets the requirements of this chapter.
History —Aug. 29, 2011, No. 194, added as § 20.050 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) › § 9357 - Corporate oversight

The chief medical officer or clinical director of the health insurance organization or issuer shall have primary responsibility for the quality assessment and quality improvement activities carried out by, or on behalf of, the health insurance organization or issuer. Furthermore, such chief medical officer or clinical director shall ensure that all requirements of this chapter are met. The chief medical officer or clinical director shall approve the written quality assessment and quality improvement programs, as applicable, implemented in compliance with this chapter, and shall periodically review and revise them. Not less than twice (2) every year, the chief medical officer or clinical director shall review reports of quality assessment and quality improvement activities. The Commissioner shall hold the health insurance organization or issuer responsible for the actions of the chief medical officer or clinical director. Also, the health insurance organization or issuer shall be responsible for ensuring that all requirements of this chapter are met.
History —Aug. 29, 2011, No. 194, added as § 20.070 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.