Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 360 - REQUIREMENTS APPLICABLE TO PREFERRED PROVIDER ARRANGEMENTS › Section 031-360-5 - Procedures for review and approval of preferred provider arrangements

Current through 2024-29, July 17, 2024
A. Unless a hearing is scheduled pursuant to
				Section
				6, the Superintendent will approve or
				disapprove the filing within 60 days of receipt of a complete filing.
B. Filing requirements. Applicants for
				preferred provider arrangements must comply with the following submission
				requirements:
(1) Complete an initial
				registration form;
(2) Provide a
				general statement of the health care services to be offered and the geographic
				area proposed to be served by the arrangement;
(3) Provide the name, address, and nature of
				any separate organization that administers the arrangement on behalf of the
				carrier or administrator;
(4)
				Describe the arrangement's relationship to existing health plans, specifying
				whether the arrangement will be offered as an alternative to coverage currently
				offered or as a replacement or modification of coverage currently offered, and
				explaining the reasons if certain classes of potential enrollees will be
				affected differently than others;
(5) Provide a list/directory of participating
				providers;
(6) Provide sample
				copies of provider contracts;
(7)
				Describe procedures, if any, for referral of enrollees to nonpreferred
				providers by a preferred provider, or by the carrier or administrator,
				including the conditions under which such referral will occur;
(8) Provide copies of contracts used
				involving a separate organization administering the arrangement on behalf of
				the carrier or administrator;
(9)
				Provide sample copies of contracts used with employers or other
				purchasers;
(10) Provide sample
				copies of contracts, certificates, or descriptive literature to be given to
				enrollees or to prospective enrollees;
(11) Describe the financial or other
				incentives for enrollees to use the services of a preferred provider or
				penalties for using nonpreferred providers;
(12) Describe provisions regarding payment
				for improper utilization of covered health services in situations where the
				enrollee has used the services of a preferred provider in compliance with the
				terms of the arrangement;
(13)
				Describe standing referral procedures regarding an enrollee with a special
				condition requiring ongoing care from a specialist;
(14) Describe procedures regarding coverage
				of the services of a nonpreferred provider if a preferred provider is not
				reasonably accessible;
(15)
				Describe utilization review procedures if review and authorization are required
				for health care services or for payment for those services, either by the
				carrier itself or by another entity contracted to perform utilization review on
				the carrier's behalf;
(16) Describe
				procedures related to the development and use of a formulary, if the carrier
				provides coverage for prescription drugs but limits that coverage to drugs
				included in a formulary;
(17)
				Describe procedures related to enrollees who wish to participate in clinical
				trials;
(18) Provide other
				information that the applicant may wish to submit which reasonably relates to
				its ability to establish, operate, maintain, or underwrite a preferred provider
				organization; and
(19) Provide such
				other information as the Superintendent may reasonably request.