reglab/statecodes huggingface dataset:
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8086 - Interstate Commission—Meetings and acts

The Commission shall meet and take those actions that are consistent with the provisions of this Compact.
All members of the Commission shall be entitled and have the power to cast their vote to which the subscribing state is entitled and to participate in the work and affairs of the Commission. Every member shall cast his/her vote in person or through the means provided through regulations. The regulations shall provide for the participation of the members at the meetings through a path or other telecommunication or electronic communication means.
The Commission shall meet at least once every calendar year. Additional meetings shall be called as provided in the regulations.
History —Dec. 22, 2005, No. 161, art. 1.6.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8089 - Resolution of controversies

At the request of a member, the Commission shall resolve all controversies or matters that may arise between two or more subscribing states as well as among the non-subscribing states. The Commission shall promulgate an operating procedure in order to provide for the resolution of said controversies.
History —Dec. 22, 2005, No. 161, 1.9.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8090 - Introduction and approval of products

The insurers and third party intermediaries that promote the approval of a product by the Commission shall introduce said product before the Commission and pay the applicable introduction fees. It shall not be construed that the provisions of this Compact restrict or prevent the insurer from introducing a product with the insurance department of any state in which the insurer is licensed to operate an insurance business. Said introduction shall be subject to the laws of the state in which the introduction is made.
The Commission shall establish suitable processes and procedures for introductions and reviews according to the regulations and operating procedures of the Commission. However, should any provision be construed in an opposite sense, the Commission shall promulgate rules to establish conditions and procedures according to which the Commission shall provide public access to the information related to the introduction of products. In establishing said rules, the Commission shall take into account the interests of the citizens in having access to said information as well as in the protection of personal medical and financial information and the business secrets that may be part of the process for introducing a product or its related information.
Any product approved by the Commission may be sold or introduced in the subscribing states in which the insurer is authorized to operate.
History —Dec. 22, 2005, No. 161, art. 1.10.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8091 - Review of the decisions

Not later than the thirty (30) days after the Commission has notified the disapproval of a publicity product or material introduced before the Commission, the insurer or third party intermediary whose introduction has been disapproved may appeal the determination before a review board appointed by the Commission. The Commission shall promulgate the rules for establishing the procedures for appointing said boards and provide for the notification and celebration of a hearing. Any allegation in the sense that the Commission in disapproving a publicity product or material introduced before the same, has acted arbitrarily, capriciously or abusively regarding its discretion or otherwise illicitly, shall be subject to judicial review.
The Commission shall be authorized to oversee, review and reconsider the publicity products and materials after they are introduced or approved when it determines that the product does not meet with the corresponding uniform standard. The Commission may withdraw or modify its approval after the proper prior notice and the celebration of a hearing, subject to the appeal process provided in this Compact.
History —Dec. 22, 2005, No. 161, art. 1.11.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8092 - Finances

The Commission shall pay or provide for the payment of reasonable expenses incurred for its establishment and organization. In order to subsidize the cost of its initial operations, the Commission may accept contributions and other types of subsidies from the National Association of Insurance Commissioners, the subscribing states and other sources. The contributions and other types of subsidies from other sources shall be of such a nature that the independence of the Commission with respect to the performance of its duties shall not be in doubt.
The Commission shall collect introduction fees from any insurer or third party intermediary that introduces a produce before the Commission and its personnel, whose total shall be sufficient to cover the annual budget of the Commission.
The budget for the Commission for the fiscal year shall not be approved until it has been presented and discussed as provided in § 8087 of this title.
The Commission shall be exempt from any taxation in the subscribing states or taxation exercised by these.
The Commission shall not pledge the credit of any subscribing state except if the Commission is given the corresponding legal authority by said subscribing state.
The Commission shall keep an account of all internal revenues, including subsidies and donations as well as of the disbursement of all funds under its control. The internal financial accounts of the Commission shall be subject to the accounting procedures provided in the statutes. The financial accounts and reports, including the internal control systems and procedures of the Commission, shall be audited annually by an independent certified public accountant. At least every three (3) years said accountant shall include an administrative and performance audit of the Commission. The Commission shall present an annual report to the Governor and to the Legislatures of the subscribing states that shall include a report of the independent audit. The internal accounts of the Commission shall not be confidential and all documents must be shared with the Commissioners who subscribe this Compact once these request them; Provided, That only those work documents related to internal or independent audits, to individual personal information and to the confidential information of the insurers, including business secrets, shall remain confidential.
No subscribing state shall be entitled to present a claim for or reclaim the title of any property of the Commission over which the Commission has a vested right nor any of the funds of the Commission possesses pursuant to the provisions of the present Compact.
History —Dec. 22, 2005, No. 161, art. 1.12.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8093 - Subscribing states, effective date and amendments

Any state shall be eligible to become a subscribing state.
The Compact shall take effect and be obligatory as of the moment in which two (2) subscribing states turn the Compact into law; Provided, That the Commission shall be effective for the purpose of adopting uniform standards for the products introduced to the Commission, for reviewing, approving or disapproving the same if they meet the uniform standards applicable, when twenty-six (26) states have become subscribing states, or as an alternative, through the approval by the states which represent over forty percent (40%) of the volume of premiums for life insurance, annuities, disability payments and long term insurance products based on the N.A.I.C. registers for the preceding year. This shall be effective and obligatory with respect to all other subscribing states when the present Compact becomes law in any of said states.
The Commission may propose amendments to the present Compact to be approved by the subscribing states. No amendment shall become effective nor be compulsory for the Commission or the subscribing states until the subscribing states approve said amendment as law.
History —Dec. 22, 2005, No. 161, art. 1.13.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8095 - Separability and construction

The provisions of the present Compact shall be separable and if it is determined that any phrase, clause or sentence cannot be enforced or is declared unconstitutional by a competent court of any participating state or territory or by the United States, the judgment rendered to that effect shall not affect, prejudice or invalidate the remaining provisions of law. All remaining parts shall have full force and effect.
The provisions of the present Compact shall be construed liberally to achieve their purpose.
History —Dec. 22, 2005, No. 161, art. 1.15.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8096 - Obligatory effect of the Compact and other laws

(a) Other laws.— Nothing of what is [herein] provided shall prevent compliance with any other law of a participating state which is not inconsistent with this Compact, except as provided in this section.
In relation to the products approved or certified by the Commission, the regulations, the uniform standards and all other requirement of the Commission shall constitute the exclusive provisions applicable to the contents, the approval and the certification of said products. As regards the publicity materials subject to the authority of the Commission, any rule, uniform standards or other requirement of the Commission that governs the contents of the publicity materials shall constitute the exclusive provision which a Commissioner may apply to the contents of said materials. However, no action taken by the Commission shall neither abrogate nor restrict: (a) the access of any person, including the Secretary of Justice and the state courts; (b) the remedies available pursuant to the state laws related to contract noncompliance, civil damages or other laws not specifically related to the contents of the product; or (c) the state laws related to the interpretation of insurance contracts.
All insurance products introduced in the individual states shall be subject to the laws of said states.
(b) Obligatory effect of the Compact.— All regulations and operating procedures promulgated by the Commission shall be of an obligatory nature with respect to the subscribing states.
All agreements between the Commission and the subscribing states shall be of an obligatory nature pursuant to their terms.
At the request of any of the parties in a controversy with respect to the meaning or construction of any action of the Commission and with the prior majority vote of the subscribing states, the Commission may issue consultative opinions with respect to the controversial meaning or construction.
In case any provision of the present Compact exceeds the constitutional limitations imposed on the Legislature of any subscribing state, the obligations, duties, powers or jurisdiction asked to be conferred upon the Commission by said provision shall not have any effect and said obligations, duties, powers or jurisdiction shall remain in the subscribing state and be exercised by the agency of the latter to which said obligations, duties, powers or jurisdiction are delegated by a law in effect when this Compact is in force.
History —Dec. 22, 2005, No. 161, art. 1.16.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9001 - Title

This subtitle constitutes the Puerto Rico Health Insurance Code and may be cited as such.
History —Aug. 29, 2011, No. 194, § 2.010, 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 100 - General Provisions (§§ 9001 — 9008) › § 9002 - Declaration of public policy

Guaranteeing the most effective regulation of the health insurance industry, including the regulation of those entities that offer group and individual health plans, is hereby adopted as public policy by the Government of Puerto Rico. As part of this public policy, it is vital to comply with the rules set forth under the Federal Health Reform and implemented through the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. Likewise, in the Commonwealth, it is necessary to gather and standardize to the extent possible, all the legal norms that shall apply to such an important industry, which has experienced an unprecedented growth in the past years, into one new law to be known as the Puerto Rico Health Insurance Code.
The main purpose of the public policy herein adopted is to provide all Puerto Ricans with access to more and better healthcare services and to promote maximum growth and development in this industry.
History —Aug. 29, 2011, No. 194, § 2.020, 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 100 - General Provisions (§§ 9001 — 9008) › § 9004 - Insurance Code of Puerto Rico

The provisions of the Insurance Code of Puerto Rico shall apply to health insurance plans and entities regulated by this Code inasmuch as they are not inconsistent with the provisions thereof.
Nothing provided in this Code shall be construed to amend or repeal the laws, regulations, or procedures administered by the Patients” Advocate Office and the Puerto Rico Health Insurance Administration (ASES) in accordance with their enabling acts.
Any issuer that enters into contracts with ASES to offer, market, or administer the Puerto Rico Government Plan (Mi Salud) shall meet the requirements and comply with the legal, regulatory, and contractual provisions established by ASES, except for matters related to the authorization or license required to engage in the insurance business in Puerto Rico, and those pertaining to financial solvency to which the Puerto Rico Insurance Code and this Code shall apply.
History —Aug. 29, 2011, No. 194, § 2.040; Sept. 29, 2012, No. 290, § 1.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9006 - Powers and duties of the Commissioner

According to this Code, the Commissioner shall have the powers, authorities, and duties vested in him/her by virtue thereof and, also, the powers, authorities, and duties established in the Insurance Code of Puerto Rico.
History —Aug. 29, 2011, No. 194, § 2.060, 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 100 - General Provisions (§§ 9001 — 9008) › § 9007 - Severability

If any provision of this Code or the applicability thereof to any person or circumstance were held to be void or invalid by a court with jurisdiction and competence, such holding shall not affect the validity of all other provisions of the Code or their applicability to persons or circumstances other than those that were held to be void or invalid.
History —Aug. 29, 2011, No. 194, § 2.070, 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 100 - General Provisions (§§ 9001 — 9008) › § 9008 - Sanctions

Any violations of the provisions of this Code or the rules or regulations promulgated thereunder for which a sanction or penalty has not been expressly prescribed shall be subject to an administrative fine of not less than five hundred dollars ($500) or more than ten thousand dollars ($10,000) for each violation.
History —Aug. 29, 2011, No. 194, § 2.080, 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 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9041 - Title

This chapter shall be known and may be cited as the chapter on Prescription Drug Management.
History —Aug. 29, 2011, No. 194, § 4.010, 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 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9042 - Purpose

The purpose of this chapter is to provide standards for the development, maintenance, and management of prescription drug formularies and other procedures as part of the prescription drug benefits established by health insurance organizations or issuers that provide such services.
History —Aug. 29, 2011, No. 194, § 4.020, 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 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9044 - Applicability and scope

This chapter shall apply to all health insurance organizations or issuers, or their designees, who provide or administer benefits for outpatient prescription drugs in accordance with the provisions of the health plan, through the use of a formulary or through the application of any other pharmaceutical benefit management procedure.
Nothing in this chapter shall be construed to apply to prescription drugs that are categorically or contractually excluded from a covered person or enrollee's health plan. A provision in the benefit contract that purports to exclude all nonformulary prescription drugs shall not be considered a categorical exclusion for purposes of this chapter.
History —Aug. 29, 2011, No. 194, § 4.040, 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 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9046 - Information to prescribers, pharmacies, covered persons or enrollees, and prospective covered persons or enrollees

(a) Health insurance organizations or issuers or pharmacy benefit managers shall meet the following requirements:
(1) Every health insurance organization or issuer or pharmacy benefits manager shall maintain and make available to covered persons or enrollees, prescribers and pharmacies, or those providing healthcare services to:
(A) Its formulary (list of prescription drugs) by therapeutic category and, in the case of pharmacy benefit managers, the list of prices known as “maximum allowable cost”;
(B) information indicating which prescription drugs, if any, are subject to a management procedure that has been developed and maintained pursuant to this chapter, and
(C) information on how and what written documentation is required to be submitted in order for covered persons or enrollees, or their authorized representatives, to file a request under the health insurance organization or issuer’s medical exceptions process established pursuant to § 9047 of this title
(2) A health insurance organization or issuer shall only make, during the term of the policy, certificate, or contract, changes in the formulary, or other prescription drugs management process if such change is being made for safety reasons or because the prescription drug cannot be supplied or has been withdrawn from the market by the drug’s manufacturer, or if such change entails the inclusion of prescription drugs in the formulary. To such effects, not later than the effective date of the change, the health insurance organization or issuer shall provide notice of, or shall entrust a third party to provide notice of that change to:
(A) All covered persons or enrollees, and
(B) participating pharmacies only if such change entails the inclusion of prescription drugs in the formulary. In such case, the issuer shall provide notice thereof thirty (30) days before the effective date of inclusion.
History —Aug. 29, 2011, No. 194, § 4.060, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 3, 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 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9048 - Record keeping and reporting requirements

(a) Each health insurance organization or issuer shall maintain sufficient written or electronic records to demonstrate compliance with this chapter, including records documenting the process for making decisions on formularies and other prescription drug management processes and records documenting the application of the medical exception request process. The records shall be maintained for a period of three (3) years or until the completion of the health insurance organization or issuer's next market conduct examination, whichever is later, and shall be made available to the Commissioner upon request.
(b) Each health insurance organization or issuer shall maintain data on and make available to the Commissioner upon request the following information with respect to medical exception requests:
(1) The total number of medical exception requests;
(2) from the total number of medical exception requests provided under clause (1):
(A) The number of requests made for coverage of a nonformulary prescription drug;
(B) the number of requests made for continuing coverage of a prescription drug that the health insurance organization or issuer was discontinuing from coverage on the formulary for reasons other than safety or because the drug cannot be supplied or has been withdrawn from the market by the drug's manufacturer, and
(C) the number of requests made for an exception to a management process that subjects a prescription drug to dose restrictions or step therapy requirements;
(3) the number of medical exceptions requests approved and denied, and
(4) any other information that the Commissioner may request.
History —Aug. 29, 2011, No. 194, § 4.080, 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 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9049 - Oversight and contracting responsibilities

(a) A health insurance organization or issuer shall be responsible for the oversight of all activities carried out under this chapter and for ensuring that all the requirements thereof and applicable regulations are met.
(b) If a health insurance organization or issuer contracts with another person to carry out activities required under this chapter or applicable regulations, the Commissioner shall hold the health insurance organization or issuer responsible for the oversight of the activities of the contracted person and for ensuring that the requirements of this chapter and applicable regulations with respect to such activity are met.
History —Aug. 29, 2011, No. 194, § 4.090, 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 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9050 - Disclosure requirements

(a) Each health insurance organization or issuer that uses a formulary or any other prescription drug management process shall, in the policy, certificate, membership booklet, outline of coverage, evidence of coverage, or any other document provided to a covered person or enrollee;
(1) Disclose the existence of the formulary and any other management processes and the fact that there may be other plan restrictions or requirements that may affect the specific prescription drugs that will be covered;
(2) describe the medical exception process that may be used to request coverage of nonformulary prescription drugs or to obtain an exception to dose restriction or step therapy requirements, and
(3) describe the process for filing a grievance, as set forth in the chapter on Health Insurance Organization or Issuer Grievance Procedure of this Code, to appeal a denial of a medical exception request.
(b) The policy, certificate, membership booklet, outline of coverage, evidence of coverage, or any other document provided to covered persons or enrollees shall explain, in layperson's terms, the information on the health insurance organization or issuer's formulary and each prescription drug management process. Such explanation shall also state that the health insurance organization or issuer shall provide covered persons or enrollees with a copy of the formulary and information about which prescription drugs are subject to a management process.
History —Aug. 29, 2011, No. 194, § 4.100, 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 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9051 - Incentive or bonus programs

(a) No pharmacy, pharmacy benefit manager (PBM), drug manufacturer or distributor, or health insurance organization or issuer shall encourage the practice or participate in incentives programs, or bonus programs or similar transactions directed to healthcare professionals in order to influence them, directly or indirectly, to write prescriptions, prescribe, dispense, or exchange certain bioequivalent drugs for a brand-name drug or vice versa.
(b) Healthcare professionals are hereby banned from receiving or participating in incentives or bonus programs, or other similar transactions, sponsored by a pharmacy, pharmacy benefit manager (PBM), drug manufacturer or distributor, or health insurance organization or issuer in order to influence healthcare professionals, directly or indirectly, to write prescriptions, prescribe, dispense, or exchange certain bioequivalent drugs for a brand-name drug or vice versa.
(c) Notwithstanding subsections (a) and (b) of this section, there shall be allowed the establishment of incentives or bonus programs, or other similar transactions based on the positive results achieved in the management or control of the clinical or health condition of covered persons or enrollees, in accordance with healthcare quality standards established by national organizations devoted to improve results in healthcare, such as the Healthcare Effectiveness Data and Information Set. These programs shall be implemented for the purpose of improving and obtaining optimum results in healthcare management and must meet the parameters that allow sufficient time to identify patterns in the results of the management or control of the clinical or health condition of covered persons or enrollees.
The persons or entities that establish incentives or bonus programs, or other similar transactions, shall submit them to the Commissioner within ninety (90) days before the effective date of such programs, so that the Commissioner may evaluate and approve the same in accordance with the provisions set forth herein. The Commissioner shall prescribe by regulations the criteria to be used to evaluate such programs. Such criteria shall take into account the healthcare quality standards established by the national organizations devoted to improve results in health care, such as the Healthcare Effectiveness Data and Information Set.
(d) The Commissioner may establish those rules and regulations deemed necessary to implement the provisions of this section.
(e) Any person who violates the provisions of this section, in addition to any other penalty established in this Code or the laws of the Government of Puerto Rico, shall be subject to a fine in an amount equal to three times the amount received or granted on account of incentives or bonuses.
History —Aug. 29, 2011, No. 194, § 4.110, 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 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9052 - Maintenance drugs

(a) When the history of the covered person or enrollee so requires, insofar as it does not jeopardize the patient's health, and at the discretion of the healthcare provider, such healthcare provider may prescribe refills for maintenance drugs up to a term that shall not exceed one hundred eighty (180) days, subject to the limitations of the healthplan's coverage.
History —Aug. 29, 2011, No. 194, § 4.120, 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 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9081 - Title

This chapter shall be known and may be cited as the chapter on Health Insurance Organizations or Issuers Claim Audit.
History —Aug. 29, 2011, No. 194, § 6.010, 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 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9082 - Purpose

The purpose of this chapter is to provide for the standardization of claim audits of bills for healthcare services presented to health insurance organizations or issuers, third party administrators, or any other health plans. Such audits shall be carried out to determine whether data in a healthcare record of a provider is supported by services listed on the claim for payment of an enrollee or a provider. It is also intended to alleviate the potential conflict of the audit with medical uses of the health record and to reduce the cost entailed by unnecessary audits.
History —Aug. 29, 2011, No. 194, § 6.020, 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 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9084 - Applicability and scope

This chapter shall apply to all health insurance organizations or issuers. The provider accepting assignment of benefits of a covered person or enrollee shall be responsible for the billing process and the results of the claim audits whether conducted by an employee or by contract with another firm. The provider and health insurance organization or issuer shall:
(a) Supervise the process to ensure that the audit is conducted in accordance with the requirements of this chapter;
(b) be aware of the actions being undertaken by the auditor in connection with the claim audit, and
(c) take prompt remedial action if inappropriate behavior by the auditor, the provider, or the person he/she designates as audit coordinator is discovered.
History —Aug. 29, 2011, No. 194, § 6.040, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 6, 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 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9085 - Qualifications of auditors and provider audit coordinators

(a) Claim auditors and provider audit coordinators shall have appropriate knowledge, experience, and expertise in the field of healthcare including, but not limited to, the following areas:
(1) Format and content of the health record as well as other forms of medical and clinical documentation;
(2) generally accepted auditing principles and practices as they apply to claim audits;
(3) billing claims forms in effect in the health insurance industry and billing procedures;
(4) all Commonwealth and federal regulations concerning the use, disclosure and confidentiality of patient records;
(5) specific critical care units, specialty area, and ancillary units involved in a particular audit, and
(6) Medical terminology and coding under updated codes, including ICD-10, CPT, and HCPCS, and as these may be reviewed and updated in the future.
(b) If a provider or health insurance organization or issuer finds that audit personnel do not meet these qualifications shall immediately contact the auditor’s firm or sponsoring party.
(c) Audit personnel shall conduct themselves in a professional manner and adhere to ethical standards and confidentiality requirements, and shall remain objective. They shall be required to completely document their findings and problems.
(d) All unsupported, unbilled or underbilled charges identified in the course of an audit shall be documented in the audit report by the auditor.
(e) Individual audit personnel shall not be placed in a situation through their remuneration, benefits, fees or other instructions that would call their findings into question. Compensation of audit personnel shall be structured so that it does not create incentives to produce questionable audit findings. Providers or health insurance organizations or issuers that encounter an individual who appears to have a conflict of interest shall contact the appropriate officers of the organization conducting the audit.
History —Aug. 29, 2011, No. 194, § 6.050, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 7, 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 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9087 - Provider audit coordinators

(a) Providers shall designate an individual to coordinate all claim audit activities. An audit coordinator shall have the same qualifications as required for an auditor pursuant to § 9085 of this title. The duties of an audit coordinator include, among others, the following:
(1) Scheduling an audit to be carried out during business hours;
(2) advising other provider personnel and departments of a pending audit;
(3) ensuring that the condition of admission statement is part of the clinical record;
(4) verifying that the auditor is an authorized representative of the health insurance organization or issuer;
(5) gathering the necessary documents for the audit;
(6) coordinating auditor requests for information, space in which to conduct an audit, and access to records and provider personnel;
(7) orienting auditors with respect to the provider’s audit procedures, record documentation conventions, and billing practices;
(8) acting as a liaison between the auditor and other personnel of the provider;
(9) conducting an exit interview with the auditor to answer questions and review audit findings;
(10) reviewing the auditor’s final written report and following up on any charges still in dispute;
(11) arranging for payment as applicable, and
(12) arranging for any required adjustment to bills or refunds.
History —Aug. 29, 2011, No. 194, § 6.070, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 9, 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 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9088 - Conditions and scheduling of audits

(a) In order to have a fair, efficient, and effective audit process, providers and health insurance organization or issuer’ [sic] auditors shall adhere to the following requirements:
(1) Whatever the original intended purpose of the claim audit, all parties shall agree to recognize, record or present any identified unsupported, unbilled or underbilled charges discovered by the audit parties;
(2) the scheduling of an audit shall not preclude late billing;
(3) the parties involved in the audit shall mutually agree to set a time frame for the resolution of any discrepancies, questions or errors that surface in the audit;
(4) an exit conference and a written report shall be part of each audit. If the provider waives the exit conference, the auditor shall note that action in the written report. The specific content of the final report shall be restricted to those parties involved in the audit;
(5) the provider shall be afforded forty (40) calendar days to contest all findings, after which the audit shall be considered final;
(6) once both parties agree to the audit findings, audit results are final;
(7) all personnel involved shall maintain a professional, courteous manner and resolve all misunderstandings amicably, and
(8) if the auditor notes ongoing problems either with the billing or documentation process and it cannot be corrected as part of the exit process, the management of the provider and health insurance organization or issuer shall be contacted to apprise them of the situation. The provider and health insurance organization or issuer shall take appropriate steps to resolve the identified problem. Parties to an audit shall eliminate ongoing problems or questions whenever possible as part of the audit process.
History —Aug. 29, 2011, No. 194, § 6.080, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 10, 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 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9089 - Confidentiality and authorizations

(a) All parties to a claim audit shall recognize and comply with all federal and Commonwealth laws and any contractual agreements regarding the protection of information within clinical records and the confidentiality and security of patient information.
(b) The release of medical records requires authorization from the patient. An authorization to release such records shall be included in the statement of diagnosis procured by the provider upon admission of the patient. If no such statement is obtained, a separate authorization for a claim audit is required. The authorization need not be specific as to the health insurance organization or issuer or auditor conducting the audit.
(c) The authorization shall be obtained by the person conducting the claim audit or the provider, and shall include the standard information provided through policy letter by the Commissioner and in accordance with subsections (a) and (b) of this section.
(d) A patient’s assignment of benefits shall include a presumption of authorization to review records.
(e) The audit coordinator shall confirm to the audit representative that a statement of diagnosis is available for the particular audit that needs scheduling.
(f) The provider shall inform the patient or requestor, on a timely basis, if there are any federal or Commonwealth laws prohibiting or restricting review of the medical record and if there are institutional confidentiality policies and procedures that affect the review of such documents. These institutional confidentiality policies shall not be specifically oriented in order to delay an external audit.
History —Aug. 29, 2011, No. 194, § 6.090, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 11, eff. 30 days after July 10, 2103.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9090 - Documentation

(a) Verification of charges shall include the investigation of whether or not:
(1) Charges are reported on the bill accurately;
(2) services are documented in medical or other records as having been rendered to the patient, and
(3) Services were delivered in compliance with the physician’s plan of treatment. In appropriate situations, professional staff may provide supplies or follow procedures that are in accordance with established institutional policies, procedures, or professional licensure standards. Many procedures include items that are not specifically documented in a clinical record but are referenced in medical or clinical policies. Such policies shall be reviewed, approved, and documented as required by the Joint Commission on Accreditation of Healthcare Organizations or other accreditation agencies. Policies shall be available for review by the auditor.
(b) The clinical record documents clinical data on diagnoses, treatments and results. It is not designed to be a billing document. A patient’s clinical record generally documents pertinent information related to care and may not back up each individual charge on the patient bill. Other signed documentation for services provided to the patient may exist within the provider’s ancillary departments in the form of department treatment logs, daily records, individual service or order tickets, and other documents.
(c) Auditors may review a number of other documents to determine valid charges. Auditors must recognize that these sources of information are accepted as reasonable evidence that the services ordered by the physician were actually provided to the patient. Providers must ensure that proper policies and procedures exist to specify what documentation and authorizations must be in the clinical record and in ancillary records and logs. These procedures must also document that services have been properly ordered for and delivered to patients. When sources other than the clinical record are furnishing documentation, the provider shall notify the auditor and make those sources available to him/her.
History —Aug. 29, 2011, No. 194, § 6.100, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 12 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 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9091 - Fees and payments

(a) A health insurance organization or issuer shall make prompt payment of a bill in accordance with the provisions of §§ 301–335 of this title and shall not delay payment for an audit process. Payment on a submitted bill from a third-party shall be based on amounts billed and covered by the patient’s health plan.
(b) Audit fees shall be paid upon commencement of the claim audit.
(c) A payment identified in the audit results that is owed to either party by the other, shall be settled by the audit parties within a reasonable period of time not to exceed thirty (30) days after completion of the audit unless the parties agree otherwise.
History —Aug. 29, 2011, No. 194, § 6.110, 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 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9121 - Title

This chapter shall be known and may be cited as the chapter on Small- and Medium-sized Businesses (PYMES, Spanish acronym) Employer Health Insurance Availability.
History —Aug. 29, 2011, No. 194, § 8.010, 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 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9122 - Purpose

The purpose of this chapter is to enhance the availability of health insurance coverage to PYMES employers regardless of their health status or claims experience, to prevent abusive rating practices, to prevent segmentation of the health insurance market based upon health risk, to require disclosure of rating practices to purchasers, to establish rules regarding renewability of coverage, to limit the use of preexisting condition exclusions, to provide for development of health plans that meet the requirements of the essential health benefit package to be offered to all PYMES employers, and to improve the overall fairness and efficiency of the small group health insurance market. This chapter shall be governed by the regulatory provisions of the Patient Protection and Affordable Care Act, as issued by federal regulatory agencies.
History —Aug. 29, 2011, No. 194, § 8.020, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 13, 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 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9124 - Applicability and scope

(a) This chapter shall apply to an issuer that offers health plans to the employees of PYMES employers in Puerto Rico, provided that the PYMES employer pays all or part of the premium or benefits, or the eligible employee is reimbursed for any portion of the premium, whether through wage adjustments or otherwise, as agreed upon by the parties.
(b) For the purposes of this chapter, issuers that are affiliated companies or that are eligible to file a consolidated tax return shall be treated as one issuer and any restrictions or limitations imposed by this chapter shall apply as if all health plans issued for delivery to PYMES employers in Puerto Rico by such affiliated issuers were issued by one issuer.
(c) Those issuers that which to contract with the Puerto Rico Health Insurance Administration (ASES, Spanish acronym) to offer, market, or administer the Mi Salud Plan for PYMES, shall meet the requirements and legal and regulatory provisions established by ASES, the Insurance Code of Puerto Rico, and this chapter. Provided, That in the case of the Mi Salud Plan for PYMES, the rules established by ASES regarding the following shall apply to issuers:
(1) Geographic service area;
(2) the criteria to determine the eligibility of the PYMES employer, as well as the employees thereof and their dependents;
(3) the development and definition of the health plan or plans and the coverage thereof;
(4) issues related to premium rate models, methods, and practices, and premiums to be paid, and
(5) the eligibility criteria to be met by participating issuers.
It is hereby provided further that those issuers that are not offering, marketing or administering a health plan for any PYMES employer in Puerto Rico and wish to contract with ASES for the Mi Salud Plan for PYMES, shall request and obtain the approval or dispensation of the Commissioner to participate in such Mi Salud Plan for PYMES.
History —Aug. 29, 2011, No. 194, § 8.040, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 15, eff. 30 days after July 2013.