2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9466 - Requirements for health insurance organizations or issuers and participating providers

A health insurance organization or issuer offering a managed care plan shall satisfy all the following requirements:
(a) A health insurance organization or issuer shall establish a mechanism whereby the participating provider will be notified on an ongoing basis of the specific covered health services for which the provider shall be responsible, including any limitations or conditions on services.
(b) Every contract between a health insurance organization or issuer and a participating provider shall set forth a hold harmless provision substantially similar to the following:
“In no event, including but not limited to nonpayment to providers, insolvency of the health insurance organization or issuer, or breach of this agreement, shall the provider bill, charge, or collect from a covered person or enrollee any amount for services provided pursuant to this agreement or have any recourse against a covered person or enrollee. Provided that this provision does not prohibit the provider from collecting coinsurance, deductibles or copayments, as specifically provided in the policy or evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to covered persons or enrollees. Except as provided herein, this agreement does not prohibit the provider from pursuing any available legal remedy.”
(c) Every contract between a health insurance organization or issuer and a participating provider shall set forth that in the event of a health insurance organization or issuer insolvency or other cessation of operations, covered services to covered persons or enrollees will continue to be offered through the period for which a premium has been paid to the health insurance organization or issuer on behalf of the covered person or enrollee or until the covered person or enrollee’s discharge from an inpatient facility, whichever time is greater. Covered benefits being offered to covered persons or enrollees confined in an inpatient facility on the date of insolvency or other cessation of operations of the health insurance organization or issuer shall continue until their continued confinement in an inpatient facility is no longer medically necessary.
(d) The contract provisions that satisfy the requirements of subsections (b) and (c) of this section shall be construed in favor of the covered person or enrollee, shall survive the termination of the contract between the health insurance organization or issuer and the provider regardless of the reason for termination, and shall supersede any oral or written contrary agreement between a provider and a covered person or enrollee.
(e) In no event shall a participating provider collect or attempt to collect from a covered person or enrollee any money owed to the provider by the health insurance organization or issuer.
(f)
(1) The health insurance organization or issuer’s selection standards shall be developed for primary care participating providers and each healthcare professional specialty. The standards shall be used by participating providers, their intermediaries, and any provider networks with which they contract in determining the selection of healthcare professionals. Selection criteria shall meet the requirements of §§ 9321–9328 of this title on Healthcare Professional Credentialing Verification and, furthermore, shall not be established in a manner:
(A) That would allow a health insurance organization or issuer to avoid high-risk populations by excluding providers because they are located in geographic areas that contain populations presenting a risk of higher than average claims, losses or health services utilization, or
(B) that would exclude providers because they treat or specialize in treating populations presenting a risk of higher than average claims, losses or health services utilization.
(2) The provisions of clause (1) of this subsection shall not be construed to prohibit a health insurance organization or issuer from declining to select a provider who fails to meet the other legitimate selection criteria of the health insurance organization or issuer developed in compliance with this chapter.
(3) The provisions of this chapter do not require a health insurance organization or issuer or the provider networks with which they contract, to employ specific providers or types of providers that meet their selection criteria, or to contract with more providers or types of providers than are necessary to maintain an adequate network.
(g) A health insurance organization or issuer shall make its selection criteria for participating providers available for review by the Commissioner.
(h) A health insurance organization or issuer shall notify participating providers of the providers’ responsibilities with respect to applicable administrative policies and programs, including but not limited to: payment terms, utilization review process, quality assessment and improvement programs, credentialing, grievance procedures, data reporting requirements, confidentiality requirements, and any applicable federal or Commonwealth programs.
(i) A health insurance organization or issuer shall not offer an inducement to a provider to provide less than medically necessary services to a covered person or enrollee.
(j) A health insurance organization or issuer shall not prohibit a participating provider from discussing other treatment options with covered persons or enrollees irrespective of the health insurance organization or issuer’s position on the treatment options, or from advocating on behalf of covered persons or enrollees within the utilization review or grievance processes established by the health insurance organization or issuer, provided that they have the authorization of the covered persons or enrollees.
(k) A health insurance organization or issuer shall require a provider to make medical records available for review or audit by the appropriate Commonwealth and federal authorities and to comply with the applicable Commonwealth and federal laws related to the confidentiality of medical or health records.
(l) The rights and responsibilities under a contract between a health insurance organization or issuer and a participating provider shall not be assigned or delegated by the provider without the prior written consent of the health insurance organization or issuer.
(m) A health insurance organization or issuer is responsible for ensuring that a participating provider furnishes covered benefits to all covered persons or enrollees without regard to the covered person or enrollee’s enrollment in the plan as a private purchaser of the plan or as a participant in a government financed program.
(n) A health insurance organization or issuer shall notify the participating providers of their obligations, if any, to collect applicable coinsurance, copayments or deductibles from covered persons or enrollees pursuant to the policy or the evidence of coverage, or of the providers’ obligations, if any, to notify covered persons or enrollees of their personal financial obligations for non-covered services.
(o) A health insurance organization or issuer shall not penalize a provider because the provider, in good faith, reports to Commonwealth and federal authorities any act or practice by the health insurance organization or issuer that jeopardizes patient health or welfare.
(p) A health insurance organization or issuer shall establish a mechanism whereby participating providers may determine in a timely manner whether or not a person is covered by the health insurance organization or issuer.
(q) A health insurance organization or issuer shall establish procedures for resolution of administrative, payment or other disputes with providers.
(r) A contract between a health insurance organization or issuer and a provider shall not contain definitions or other provisions that conflict with the definitions or provisions contained in the managed care plan or this Code.
(s) A health insurance organization or issuer shall include in their contracts with participating providers an adequate summary of the benefit coordination clause, which shall be governed by the provisions of the current NAIC’s Model Act and the federal laws regarding the coordination of benefits. Participating providers shall be responsible for coordinating benefits with health insurance organizations or issuers in the event a covered person or enrollee has coverage under two (2) or more health plans.
History —Aug. 29, 2011, No. 194, added as § 26.060 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.