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) › § 9467 - Intermediaries

A contract between a health insurance organization or issuer and an intermediary shall satisfy all the requirements contained in this section:
(a) Intermediaries and participating providers with whom they contract shall meet all the requirements of § 9466 of this title.
(b) A health insurance organization or issuer’s responsibility to monitor the offering of healthcare services to covered persons or enrollees shall not be delegated or assigned to the intermediary.
(c) In exercising its freedom of contract, a health insurance organization or issuer shall have the right to approve or disapprove participation of a provider or a provider network contracted by the intermediary. Reasons to disapprove the participation of a particular participating provider include, but are not limited to:
(1) License to practice medicine or profession has been revoked or suspended upon a final and binding determination by competent authorities;
(2) the provider has been arrested or convicted of a felony or misdemeanor involving moral turpitude;
(3) the provider was a participating provider in the health insurance organization or issuer’s network and was expelled therefrom due to breach of contract, fraud or other grounds;
(4) the provider is among the listing of providers excluded from participation in federal health programs or any other similar federal listing;
(5) the provider’s misconduct toward covered persons or enrollees, and
(6) the provider has incurred unfair debt collection practices with respect to the health insurance organization or issuer or covered persons or enrollees.
(d) A health insurance organization or issuer shall maintain copies of all intermediary healthcare subcontracts at its principal place of business in Puerto Rico, or ensure that it has access to all intermediary subcontracts, including the right to make copies to facilitate regulatory review.
(e) If applicable, an intermediary shall furnish utilization documentation and claims paid documentation to the health insurance organization or issuer. The health insurance organization or issuer shall monitor the timeliness and appropriateness of payments made to providers and healthcare services received by covered persons or enrollees.
(f) If applicable, an intermediary shall maintain the books, records, financial information, and documentation of services provided to covered persons or enrollees at its principal place of business in Puerto Rico and preserve them as provided in § 952f of this title in a manner that facilitates regulatory review.
(g) An intermediary shall allow the Commissioner access to the intermediary’s books, records, financial information and any documentation of services provided to covered persons or enrollees, as necessary to determine compliance with this chapter.
(h) A health insurance organization or issuer shall have the right, in the event of the intermediary’s insolvency, to require the assignment to the health insurance organization or issuer of the contract provisions addressing the provider’s obligation to furnish covered services.
History —Aug. 29, 2011, No. 194, added as § 26.070 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.