reglab/statecodes huggingface dataset:
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0200 - CONTRACTS BETWEEN NETWORK PLAN CARRIERS AND HEALTHCARE PROVIDERS › Section 20 .0201 - WRITTEN CONTRACTS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) All contracts
				between network plan carriers and health care providers and between network
				plan carriers and intermediary organizations offering networks of health care
				providers to be used by network plan carriers for the provision of care on a
				preferred or in-network basis shall be in writing and shall comply with
				11 NCAC
				20 .0202 as a condition of such health care
				providers' and networks' being listed in the carrier's provider
				directory.
(b) The form of every
				contract under Paragraph (a) of this Rule shall be filed with the Division for
				approval according to these Rules before it is used.
(c) As used in this Section and in Section
				.0600 of this Chapter, "Division" means the Life and Health Division of the
				Department of Insurance.
Authority
				  G.S.
				  58-2-40(1);
				  58-50-50;
				  58-50-55;
				  58-65-25;
				  58-65-140;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Amended Eff. July 1, 2006;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0200 - CONTRACTS BETWEEN NETWORK PLAN CARRIERS AND HEALTHCARE PROVIDERS › Section 20 .0202 - CONTRACT PROVISIONS

Current through Register Vol. 39, No. 2, July 15, 2024
All contract forms shall contain provisions addressing the
				  following:
(1) Whether the contract
				and any attached or incorporated amendments, exhibits, or appendices constitute
				the entire contract between the parties.
(2) Definitions of technical insurance or
				managed care terms used in the contract, and whether those definitions
				reference other documents distributed to providers and are consistent with
				definitions included in the evidence of coverage issued in conjunction with the
				network plan.
(3) Term of the
				contract.
(4) Any requirements for
				written notice of termination and each party's grounds for
				termination.
(5) The provider's
				continuing obligations after termination of the provider contract or in the
				case of the carrier or intermediary's insolvency. The obligations shall
				address:
(a) Transition of administrative
				duties and records.
(b)
				Continuation of care, when inpatient care is on-going. If the carrier provides
				or arranges for the delivery of health care services on a prepaid basis,
				inpatient care shall be continued until the patient is ready for
				discharge.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0200 - CONTRACTS BETWEEN NETWORK PLAN CARRIERS AND HEALTHCARE PROVIDERS › Section 20 .0203 - CHANGES REQUIRING APPROVAL

Current through Register Vol. 39, No. 2, July 15, 2024
All material changes to an approved contract form shall be
				  filed with the Division for approval before use. For the purpose of this Rule,
				  a "material change" includes a change in:
(1) the means of calculating payment to the
				provider; for example, change from fee for service to capitation;
(2) the distribution of risk between parties;
				or
(3) the delegation of clinical
				and administrative responsibilities.
Authority
				  G.S.
				  58-2-40(1);
				  58-65-25;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-115;
				  58-67-120;
				  58-67-150;
Eff.
				  October 1, 1996;
Readopted Eff. December 1,
				  2017.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0200 - CONTRACTS BETWEEN NETWORK PLAN CARRIERS AND HEALTHCARE PROVIDERS › Section 20 .0204 - CARRIER AND INTERMEDIARY CONTRACTS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) If a
				carrier contracts with an intermediary for the provision of a network to
				deliver health care services, the carrier shall file with the Division for
				prior approval its form contract with the intermediary. The filing shall be
				accompanied by a certification from the carrier that the intermediary will, by
				the terms of the contract, be required to comply with all statutory and
				regulatory requirements that apply to the functions delegated. The
				certification shall also state that the carrier shall monitor such
				compliance.
(b) A carrier's
				contract form with the intermediary shall state that:
(1) All provider contracts used by the
				intermediary shall comply with the provisions of Rule .0202 of this
				Section.
(2) The network carrier
				retains its legal responsibility to monitor and oversee the offering of
				services to its members and financial responsibility to its members.
(3) The intermediary may not subcontract for
				its services without the carrier's written permission.
(4) The carrier may approve or disapprove
				participation of individual providers contracting with the intermediary for
				inclusion in or removal from the carrier's own network plan.
(5) The carrier shall retain copies or the
				intermediary shall make available for review by the Department all provider
				contracts and subcontracts held by the intermediary.
(6) If the intermediary organization assumes
				risk from the carrier or pays its providers on a risk basis or is responsible
				for claims payment to its providers:
(A) The
				carrier shall receive documentation of utilization and claims payment and
				maintain accounting systems and records.
(B) The carrier shall arrange for financial
				protection of itself and its members through such approaches as member hold
				harmless language, retention of signatory control of the funds to be disbursed,
				or financial reporting requirements.
(C) To the extent provided by law, the
				Department shall have access to the books, records, and financial information
				to examine activities performed by the intermediary on behalf of the carrier.
				Such books and records shall be maintained in North Carolina.
(7) The intermediary shall comply
				with all statutory and regulatory requirements that apply to the functions
				delegated by the carrier and assumed by the intermediary.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0200 - CONTRACTS BETWEEN NETWORK PLAN CARRIERS AND HEALTHCARE PROVIDERS › Section 20 .0205 - FILING REQUIREMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
All contract form filings shall be submitted to the
				  Department in the following manner:
(1) New managed care contract forms shall be
				submitted in either paper or an electronic format in accordance with
				11 NCAC
				12 .0329.
(2) Amendments to contract forms shall
				include both a red-line formatted copy and a clean copy of the
				contract.
(3) Each contract form
				shall be designated by a unique form number assigned by the carrier for
				identification purposes that shall not exceed the length of 70 character
				spaces.
(4) Contract form filings
				shall be held open for a 60-day period beginning on the date that the Division
				receives the submission. If the submission is not brought into compliance
				within that period, the file shall be formally disapproved and
				closed.
Authority
				  G.S.
				  58-2-40(1);
				  58-50-50;
				  58-50-55;
				  58-65-25;
				  58-65-140;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-150;
Eff.
				  October 1, 1996;
Amended Eff. July 1, 2006;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0300 - PROVIDER ACCESSIBILITY AND AVAILABILITY › Section 20 .0301 - PROVIDER AVAILABILITY STANDARDS

Current through Register Vol. 39, No. 2, July 15, 2024
Each network plan carrier shall develop a methodology to
				  determine the size and adequacy of the provider network necessary to serve the
				  members. The methodology shall provide for the development of performance
				  targets that shall address the following:
(1) The number and type of primary care
				physicians, specialty care providers, hospitals, and other provider facilities,
				as defined by the carrier.
(2) A
				method to determine when the addition of providers to the network will be
				necessary based on increases in the membership of the network plan
				carrier.
(3) A method for arranging
				or providing health care services outside of the service area when providers
				are not available in the area.
Authority
				  G.S.
				  58-2-40(1);
				  58-65-1;
				  58-65-25;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Readopted Eff. June 1,
				  2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0300 - PROVIDER ACCESSIBILITY AND AVAILABILITY › Section 20 .0302 - PROVIDER ACCESSIBILITY STANDARDS

Current through Register Vol. 39, No. 2, July 15, 2024
Each carrier shall establish performance targets for member
				  accessibility to primary and specialty care physician services and
				  hospital-based services. Carriers shall also establish similar performance
				  targets for health care services provided by providers who are not physicians.
				  Carriers shall establish written policies and performance targets that address
				  the following:
(1) The proximity of
				network providers, as measured by such means as driving distance or time a
				member must travel to obtain primary care, specialty care, and hospital
				services, taking into account local variations in the supply of providers, and
				geographic considerations.
(2) The
				availability to provide emergency services on a 24-hour, 7 day per week
				basis.
(3) Emergency provisions
				within and outside of the service area.
(4) The average or expected waiting time for
				urgent, routine, and specialist appointments.
Authority
				  G.S.
				  58-2-40(1);
				  58-65-1;
				  58-65-25;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Readopted Eff. June 1,
				  2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0300 - PROVIDER ACCESSIBILITY AND AVAILABILITY › Section 20 .0303 - EXPIRED - PROVIDER NETWORK SAFEGUARDS

Current through Register Vol. 39, No. 2, July 15, 2024
Authority
				  G.S.
				  58-2-40(1);
				  58-50-55(b);
				  58-65-1;
				  58-65-25;
				  58-65-140;
				  58-67-10;
				  58-67-20;
58-67-35;
				  58-67-65; 58-67-140; 58-67-150;
Eff. October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule Expired January 1,
				  2015.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0300 - PROVIDER ACCESSIBILITY AND AVAILABILITY › Section 20 .0304 - MONITORING ACTIVITIES

Current through Register Vol. 39, No. 2, July 15, 2024
Each carrier shall, by means of site visits or review of
				  information gathered by the carrier, monitor compliance with this Section and
				  evaluate provider availability and accessibility at least annually to ensure
				  that the needs of its members are met. The documentation of these activities
				  shall be maintained by domestic carriers for a period of five years or until
				  the completion of the next quintennial examination conducted by the Department,
				  whichever is later. Foreign carriers shall maintain the documentation of these
				  activities for a period of at least five years.
Authority
				  G.S.
				  58-2-40(1);
				  58-2-131;
				  58-50-55(b);
				  58-65-1;
				  58-65-25;
				  58-65-105;
				  58-65-140;
58-67-10;
				  58-67-20; 58-67-35; 58-67-65; 58-67-100; 58-67-140; 58-67-150;
Eff.
				  October 1, 1996;
Amended Eff. January 1, 2009;
Pursuant
				  to G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0401 - CREDENTIAL VERIFICATION PROGRAM

Current through Register Vol. 39, No. 2, July 15, 2024
In order to assure accessibility and availability of
				  services, each carrier shall establish a program in accordance with this
				  Section that verifies that its network providers are credentialed before the
				  carrier lists those providers in the carrier's provider directory, handbooks,
				  or other marketing or member materials.
Authority
				  G.S.
				  58-2-40(1);
				  58-50-55(b);
				  58-65-1;
				  58-65-25;
				  58-65-140;
				  58-67-5;
				  58-67-10;
58-67-20;
				  58-67-35; 58-67-65; 58-67-140; 58-67-150;
Eff. October 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0402 - ORGANIZATION STRUCTURE

Current through Register Vol. 39, No. 2, July 15, 2024
The program established under Rule .0401 of this Section
				  shall provide for an identifiable person or persons to be responsible for all
				  credential verification activities, which person or persons shall be capable of
				  carrying out that responsibility.
Authority
				  G.S.
				  58-2-40(1);
				  58-50-55(b);
				  58-65-1;
				  58-65-25;
				  58-65-140;
				  58-67-5;
				  58-67-10;
58-67-20;
				  58-67-35; 58-67-65; 58-67-140; 58-67-150;
Eff. October 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0403 - WRITTEN CREDENTIAL VERIFICATION PLAN

Current through Register Vol. 39, No. 2, July 15, 2024
Each carrier shall develop and adopt a written credentialing
				  plan that contains policies and procedures to support the credential
				  verification program. The plan shall include:
(1) The purpose, goals, and objectives of the
				credential verification program.
(2) The roles of those persons responsible
				for the credential verification program.
Authority
				  G.S.
				  58-2-40(1);
				  58-50-55(b);
				  58-65-1;
				  58-65-25;
				  58-65-105;
				  58-65-140;
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0404 - APPLICATION

Current through Register Vol. 39, No. 2, July 15, 2024
For all providers who submit applications to be added to a
				  carrier's network:
(1) The definitions
				in G.S.
				58-3-167 are incorporated into this Rule by
				reference. Each carrier that is an insurer that issues a health benefit plan
				shall obtain and retain on file each provider's signed and dated application on
				the form approved by the Commissioner under
				G.S.
				58-3-230. All required information shall be
				current upon final approval of the provider by the carrier. The application
				shall include, when applicable:
(a) The
				provider's name, address, and telephone number.
(b) Practice information, including call
				coverage.
(c) Education, training,
				and work history.
(d) The current
				provider license, registration, or certification, and the names of other states
				where the applicant is or has been licensed, registered, or
				certified.
(e) Drug Enforcement
				Agency (DEA) registration number and prescribing restrictions.
(f) Specialty board or other
				certification.
(g) Professional and
				hospital affiliation.
(h) The
				amount of professional liability coverage and any malpractice
				history.
(i) Any disciplinary
				actions by medical organizations and regulatory agencies.
(j) Any felony or misdemeanor
				convictions.
(k) The type of
				affiliation requested, for example, primary care, consulting specialists,
				ambulatory care.
(l) A signed and
				dated statement by the provider attesting that the information provided is
				true, accurate, and complete, and authorizing the release of information and
				materials related to the provider's qualifications and competence.
(m) Letters of reference or recommendation or
				letters of oversight from supervisors, or both, that attest to the
				qualifications or competence of the provider or otherwise recommend approval of
				the provider's application.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0406 - PROVIDER FILES

Current through Register Vol. 39, No. 2, July 15, 2024
Each carrier shall maintain centralized files, either paper
				  or electronic, on each individual provider making application to affiliate with
				  the carrier. Each file shall include documentation of compliance with Rules
				  .0404 and .0405 of this Section.
Authority
				  G.S.
				  58-2-40(1);
				  58-2-131;
				  58-50-55(b);
				  58-65-1;
				  58-65-25;
				  58-65-105;
				  58-65-140;
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-100;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0407 - REVERIFICATION OF PROVIDER CREDENTIALS

Current through Register Vol. 39, No. 2, July 15, 2024
Each carrier shall reverify the credentials of all network
				  providers at least every three years. On or after October 1, 2001, carriers
				  shall use the form approved by the Commissioner under
				  G.S.
				  58-3-230. Carriers may require completion of
				  all or only selected sections of the form for reverification of
				  credentials.
Authority
				  G.S.
				  58-2-40(1);
				  58-3-230;
				  58-65-1;
				  58-65-25;
				  58-65-105;
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Temporary Amendment Eff. October 1,
				  2001;
Amended Eff. August 1, 2002;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0408 - CONFIDENTIALITY

Current through Register Vol. 39, No. 2, July 15, 2024
Each carrier shall develop written policies and procedures to
				  protect the confidentiality of patient health or medical record information and
				  personal information, as provided by law.
Authority
				  G.S.
				  58-2-40(1);
				  58-2-131;
				  58-39-45;
				  58-39-75;
				  58-50-55(b);
				  58-65-1;
				  58-65-25;
				  58-65-105;
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-100;
				  58-67-140;
				  58-67-180;
Eff.
				  October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0409 - EXPIRED - RECORDS AND EXAMINATIONS

Current through Register Vol. 39, No. 2, July 15, 2024
Authority
				  G.S.
				  58-2-40(1);
				  58-2-131;
				  58-50-55(b);
				  58-65-1;
				  58-65-25;
				  58-65-105;
				  58-65-140;
58-67-5;
				  58-67-10; 58-67-20; 58-67-35; 58-67-65; 58-67-100; 58-67-140;
				  58-67-150;
Eff. October 1, 1996;
Amended Eff. January
				  1, 2009;
Pursuant to
				  G.S.
				  150B-21.3A, rule Expired January 1,
				  2015.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0410 - DELEGATION OF CREDENTIAL VERIFICATION ACTIVITIES

Current through Register Vol. 39, No. 2, July 15, 2024
Whenever any carrier delegates credential verification
				  activities to a contracting entity, whether an intermediary or subcontractor,
				  the carrier shall review the contracting entity's credential verification
				  program before contracting to ensure that the entity complies with all
				  applicable requirements in this Section. The carrier shall monitor the
				  contracting entity's credential verification activities. The carrier shall
				  implement oversight mechanisms, including:
(1) Reviewing the contracting entity's
				credential verification plans, policies, procedures, forms, and adherence to
				verification procedures.
(2)
				Requiring the contract entity to submit an updated list of providers
				quarterly.
(3) Conducting an
				evaluation of the contracting entity's credential verification program every
				three years.
Authority
				  G.S.
				  58-2-40(1);
				  58-65-1;
				  58-65-25;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Readopted Eff. December 1,
				  2017.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0411 - SUSPENSION OR TERMINATION OF NETWORK PROVIDERS

Current through Register Vol. 39, No. 2, July 15, 2024
Each carrier shall have a mechanism in place to reduce,
				  suspend, or terminate the participation of any network
				  provider.
Authority
				  G.S.
				  58-2-40(1);
				  58-50-55(b);
				  58-65-1;
				  58-65-25;
				  58-65-105;
				  58-65-140;
				  58-67-5;
58-67-10;
				  58-67-20; 58-67-35; 58-67-65; 58-67-140; 58-67-150;
Eff. October 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0501 - PROGRAM

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Each HMO shall
				have a program designed to monitor, evaluate, improve, and promote:
(1) The quality of health care and quality of
				services provided through its network of providers; and
(2) Its policies, procedures, and
				performance.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0502 - STRUCTURE

Current through Register Vol. 39, No. 2, July 15, 2024
Each HMO shall develop and maintain an organizational
				  structure to conduct quality management. The structure shall provide for an
				  identifiable person or persons to be responsible for all quality management,
				  which person or persons shall be capable of carrying out that
				  responsibility.
Authority
				  G.S.
				  58-2-40(1);
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-100;
				  58-67-140;
58-67-150;
Eff. October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0503 - PLAN

Current through Register Vol. 39, No. 2, July 15, 2024
Each HMO shall develop and adopt a written quality management
				  plan that contains policies and procedures to support the quality management
				  program. This plan shall include the following:
(1) The purpose, goals, and objectives of the
				quality management program.
(2) The
				role of those responsible for all quality management programs.
(3) The specific services to be monitored in
				accordance with
				11 NCAC
				20 .0501.
Authority
				  G.S.
				  58-2-40(1);
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-100;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0504 - ACTIVITIES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Each HMO shall
				develop quality of care and quality of service standards and establish a
				mechanism to determine if the standards are being met.
(b) Each HMO shall employ a variety of
				quality management tools that assess and monitor:
(1) The quality of health care and quality of
				service and that takes into account treatment settings for all types of medical
				care that have been provided through its network of providers; and
(2) Administrative and utilization management
				decisions of the carrier.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0505 - QUALITY OF CARE COMPLAINTS

Current through Register Vol. 39, No. 2, July 15, 2024
Each HMO shall maintain policies and procedures to record,
				  investigate, and take corrective action in response to patient complaints about
				  the quality of care delivered by network providers and decisions made by the
				  HMO. The policies and procedures shall provide for the following:
(1) Complaints about quality of care issues
				shall be forwarded to and investigated by individuals who are capable of
				performing that function.
(2) A
				method of aggregating, categorizing, and analyzing quality of care complaints
				relating to provider performance or HMO policies or procedures.
Authority
				  G.S.
				  58-2-40(1);
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-100;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0506 - DELEGATION OF ACTIVITIES

Current through Register Vol. 39, No. 2, July 15, 2024
Whenever any HMO delegates quality management activities to
				  another entity, the HMO shall review and approve the entity's quality
				  management program before contracting with the entity and shall monitor the
				  entity's quality management activities. The HMO shall implement oversight
				  mechanisms, including:
(1) Reviewing
				the contracting entity's quality management plans, policies, procedures,
				activities, and provider contracting forms; and verifying that they meet the
				HMO's standards.
(2) Requiring the
				contracting entity to submit, at least annually, reports of its quality
				management activities and operations.
(3) Conducting audits of the contracting
				entity's quality assurance activities and operations.
Authority
				  G.S.
				  58-2-40(1);
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0507 - CORRECTIVE ACTION

Current through Register Vol. 39, No. 2, July 15, 2024
Each HMO shall have procedures for identifying and taking
				  corrective action on quality of care and quality of service problems related to
				  network providers or the carrier, whether a specific individual or
				  system-wide.
Authority
				  G.S.
				  58-2-40(1);
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0508 - CONFLICTS OF INTEREST

Current through Register Vol. 39, No. 2, July 15, 2024
Each HMO shall develop written policies and procedures about
				  conflicts of interest. No person shall conduct utilization review of health
				  care provided by any facility or entity in which that person or any member of
				  his or her family has, directly or indirectly, a financial interest. That
				  person shall recuse himself or herself from such review.
Authority
				  G.S.
				  58-2-40(1);
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0509 - CONFIDENTIALITY

Current through Register Vol. 39, No. 2, July 15, 2024
Each HMO shall develop written policies and procedures to
				  protect the confidentiality of medical record information and personal
				  information relating to covered individuals, as those terms are defined in
				  G.S.
				  58-39-15.
Authority
				  G.S.
				  58-2-40(1);
				  58-39-45;
				  58-39-75;
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
58-67-140;
				  58-67-150; 58-67-180;
Eff. October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0510 - EXPIRED - RECORDS AND EXAMINATIONS

Current through Register Vol. 39, No. 2, July 15, 2024
Authority
				  G.S.
				  58-2-40(1);
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-100;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Amended Eff. January 1, 2009;
Pursuant
				  to G.S.
				  150B-21.3A, rule Expired January 1,
				  2015.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0500 - HMO QUALITY MANAGEMENT PROGRAMS › Section 20 .0511 - INTERNAL AUDIT

Current through Register Vol. 39, No. 2, July 15, 2024
Each HMO shall at least annually evaluate its quality
				  management program to assure that it complies with this Section and the HMO's
				  internal standards, policies, and procedures. The effectiveness and efficiency
				  of the program shall also be evaluated. The results of the evaluation shall be
				  used in continuous improvement efforts.
Authority
				  G.S.
				  58-2-40(1);
				  58-67-5;
				  58-67-10;
				  58-67-20;
				  58-67-35;
				  58-67-65;
				  58-67-140;
				  58-67-150;
Eff.
				  October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0600 - SIGNIFICANT MODIFICATIONS TO HMO OPERATIONS › Section 20 .0601 - APPLICATIONS FOR MODIFICATIONS TO SERVICE AREAS OR PRODUCT LINES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) All requests to expand an HMO's service
				area shall be submitted in electronic format as an application to the Division
				for review and approval. The application shall include the following
				information:
(1) a description of operational
				changes that will result from the expansion;
(2) financial and actuarial information as
				required by
				11 NCAC
				11C .0311 and
				11 NCAC
				16 .0605;
(3) a description of provider interest and
				network development in the service area requested and information as to the
				HMO's existing provider network; and
(4) copies of any form contracts to be made
				as a result of the expansion, including providers and subcontractors.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0600 - SIGNIFICANT MODIFICATIONS TO HMO OPERATIONS › Section 20 .0602 - WRITTEN NOTICE

Current through Register Vol. 39, No. 2, July 15, 2024
In addition to those modifications set out in
				  G.S.
				  58-67-10(d)(1), an HMO shall
				  submit written notice to the Division of the following:
(1) Changes to the members of the HMO's Board
				of Directors, Trustees, Officers, or any entity maintaining at least 10 percent
				ownership in the HMO, within 15 days after the change.
(2) Reductions in the number of providers
				that exceed 10 percent of the total number of providers in a particular service
				area within 15 days after the change.
(3) Any application made in any other state
				for licensure as an HMO, insurance company or any other type of managed care
				organization, within 15 days after making the application.
(4) Any application made in North Carolina or
				any other state to engage in business arrangements involving Medicare,
				Medicaid, CHAMPUS or Workers Compensation, within 15 days after making the
				application.
Authority
				  G.S.
				  58-2-40;
				  58-67-10;
				  58-67-150;
Eff.
				  October 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 21 - THIRD PARTY ADMINISTRATORS › Section .0100 - GENERAL PROVISIONS › Section 21 .0101 - DEFINITIONS: LICENSE APPLICATIONS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The
				definitions in
				G.S.
				58-56-2 are incorporated into this Chapter by
				reference.
(b) In addition to those
				items listed in
				G.S.
				58-56-51, the following items shall be filed
				in order to constitute a complete application for initial or renewal TPA
				licensure:
(1) Transmittal form;
(2) An application for administrator's
				license;
(3) Biographical form(s)
				completed by principal officers;
(4) A narrative description specifying the
				TPA's services performed in North Carolina;
(5) A power of attorney duly executed by the
				TPA, if not domiciled in North Carolina, appointing the Commissioner as
				attorney for the TPA in and for this State, upon whom process in any legal
				action or proceeding against the TPA on a cause of action arising in this State
				may be served;
(6) Internal
				controls narrative; and
(7)
				Administrator's questionnaire.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 21 - THIRD PARTY ADMINISTRATORS › Section .0100 - GENERAL PROVISIONS › Section 21 .0102 - FINANCIAL STATEMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
The financial statements required by
				  G.S.
				  58-56-51(b)(4) shall include
				  a balance sheet, a statement of operations, and a statement of cash flows for
				  the TPA's two most recent fiscal years. Financial statements shall be prepared
				  by an independent certified public accountant. Financial statements of a TPA's
				  parent company are acceptable if those statements contain consolidating
				  schedules that include a breakout of the finances of the TPA, and if the
				  certified public accountant's opinion letter does not disclaim association with
				  the consolidating schedules.
Authority
				  G.S.
				  58-2-40;
				  58-2-205;
				  58-56-51;
Eff. June 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 21 - THIRD PARTY ADMINISTRATORS › Section .0100 - GENERAL PROVISIONS › Section 21 .0103 - DETERMINATION OF FINANCIAL RESPONSIBILITY

Current through Register Vol. 39, No. 2, July 15, 2024
In determining the financial responsibility of an applicant
				  for a TPA license, the Department shall require that an applicant be solvent.
				  In addition, the Department shall consider:
(1) Liquidity;
(2) Any internal controls the applicant may
				have in place to afford protection for benefit plans, which may include the
				manner in which benefit plan fund accounts are established; and
(3) Segregation of duties.
Authority
				  G.S.
				  58-2-40;
				  58-56-51;
Eff. June 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 21 - THIRD PARTY ADMINISTRATORS › Section .0100 - GENERAL PROVISIONS › Section 21 .0104 - SERVICE CONTRACTS

Current through Register Vol. 39, No. 2, July 15, 2024
No TPA shall enter into an agreement to administer insurance
				  with an insurance company or health maintenance organization unless the company
				  or HMO is licensed to operate in North Carolina.
Authority
				  G.S.
				  58-2-40;
				  58-56-6;
				  58-56-51;
Eff. June 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 21 - THIRD PARTY ADMINISTRATORS › Section .0100 - GENERAL PROVISIONS › Section 21 .0105 - CLAIM ADJUSTING BY TPAS

Current through Register Vol. 39, No. 2, July 15, 2024
A TPA or an employee of a TPA does not have to have a license
				  to adjust insurance claims for an insurer with which the TPA has a written
				  agreement under
				  G.S.
				  58-56-6.
Authority
				  G.S.
				  58-2-40;
				  58-56-2(5);
				  58-56-51;
Eff. June 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 21 - THIRD PARTY ADMINISTRATORS › Section .0100 - GENERAL PROVISIONS › Section 21 .0106 - PAYMENT OF CLAIMS

Current through Register Vol. 39, No. 2, July 15, 2024
If claims filed with a TPA or insurer are not paid within 30
				  days after receipt of the initial claim by the TPA or the insurer, the TPA or
				  the insurer shall at that time mail a claim status report to the
				  claimant.
Authority
				  G.S.
				  58-2-40;
				  58-3-100;
				  58-56-31;
Eff. June 1,
				  1996;
Readopted Eff. December 1,
				  2017.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 21 - THIRD PARTY ADMINISTRATORS › Section .0100 - GENERAL PROVISIONS › Section 21 .0107 - GENERAL ADMINISTRATION

Current through Register Vol. 39, No. 2, July 15, 2024
Every TPA shall:
(1)
				Establish a governing body that is authorized to set policy for the
				organization.
(2) Maintain complete
				corporate records in a secure and accessible location.
(3) Employ a management information system
				that is able to provide information on all areas of the TPA
				operations.
(4) Set internal
				policies and procedures for contract management.
Authority
				  G.S.
				  58-2-40;
				  58-56-6;
				  58-56-16;
				  58-56-51;
Eff. June 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 21 - THIRD PARTY ADMINISTRATORS › Section .0100 - GENERAL PROVISIONS › Section 21 .0108 - CLAIMS ADMINISTRATION

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Each TPA's
				claims administration service shall be supported by a set of written policies,
				procedures, and performance standards related to timeliness in payment of
				claims and its financial operations.
(b) Each TPA shall develop and implement a
				claims administration internal audit and a quality assurance program to monitor
				and improve claims processing services.
Authority
				  G.S.
				  58-2-40;
				  58-56-26;
				  58-56-31;
				  58-56-51;
Eff. June 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 21 - THIRD PARTY ADMINISTRATORS › Section .0100 - GENERAL PROVISIONS › Section 21 .0109 - MARKETING AND SALES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Each TPA shall
				ensure that all direct sales staff and brokers are licensed by the State of
				North Carolina to sell insurance and meet all continuing education
				requirements.
(b) Each TPA that
				markets or sells insurance products shall quote only premium rates that have
				been filed with, and if applicable, approved by the Commissioner for those
				products. Where premium rates accompany a policy form filing and the rates are
				not subject to approval but the policy form filing is subject to approval, the
				TPA shall not quote those premium rates until the related forms have been
				approved by the Commissioner.
Authority
				  G.S.
				  58-2-40;
				  58-56-31;
				  58-56-51;
				  58-63-15;
				  58-63-65;
Eff. June 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 21 - THIRD PARTY ADMINISTRATORS › Section .0100 - GENERAL PROVISIONS › Section 21 .0110 - SERVICES TO INSUREDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Each TPA shall
				make available to insureds and insurers a written description of its premium
				collection and claims payment policies and procedures.
(b) Each TPA shall be accessible to insureds
				and insurers by telephone to respond to inquiries about premium collections and
				claims payments.
Authority
				  G.S.
				  58-2-40;
				  58-56-41;
				  58-56-51;
Eff. June 1,
				  1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 16,
				  2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 22 - PEO TRUSTS › Section 22 .0101-.0116 - EXPIRED

Current through Register Vol. 39, No. 2, July 15, 2024
Authority
				G.S.
				58-2-40;
				58-89A-15;
				58-89A-105;
				58-89A-106;
Eff. April
				1, 2010;
Pursuant to
				G.S.
				150B-21.3A, rules Expired January 1,
				2015.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter A - WORKERS' COMPENSATION RULES › Section .0100 - ADMINISTRATION › Section 23A .0101 - LOCATION OF MAIN OFFICE AND HOURS OF BUSINESS

Current through Register Vol. 39, No. 2, July 15, 2024
The main office of the North Carolina Industrial Commission
					 is located in the Dobbs Building, 430 North Salisbury Street, Raleigh, North
					 Carolina. Documents that may be filed via hand-delivery in accordance with Rule
					 .0108 of this Section may be filed at the main office between the hours of 8:00
					 a.m. and 5:00 p.m. only. Documents permitted to be filed electronically may be
					 filed until 11:59 p.m. on the required filing date.
Authority
					 G.S.
					 97-80(a);
Eff.
					 January 1, 1990;
Amended Eff. January 1, 2016; November 1, 2014;
					 January 1, 2011; June 1, 2000;
Recodified from
					 04 NCAC
					 10A .0101 Eff. June 1, 2018;
Amended Eff. December 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter A - WORKERS' COMPENSATION RULES › Section .0100 - ADMINISTRATION › Section 23A .0102 - OFFICIAL FORMS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Copies of the
				  Commission's rules and forms may be obtained by:
(1) contacting the Commission in person at
				  the address in Rule .0101 of this Section, by written request mailed to North
				  Carolina Industrial Commission, 1236 Mail Service Center, Raleigh, NC
				  27699-1236, Attn.: Office of the Clerk, or
(2) accessing or downloading the rules or
				  forms from the Commission's website at
http://www.ic.nc.gov/abtrules.html
and
http://www.ic.nc.gov/forms.html
.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter A - WORKERS' COMPENSATION RULES › Section .0100 - ADMINISTRATION › Section 23A .0103 - NOTICE OF ACCIDENT AND CLAIM OF INJURY OR OCCUPATIONAL DISEASE

Current through Register Vol. 39, No. 2, July 15, 2024
To give notice of an accident or occupational disease and
					 to make a workers' compensation claim, an employee may complete a Form 18
					 Notice of Accident to Employer and Claim of Employee, Representative, or
					 Dependent and file it in accordance with Rule .0108 of this
					 Section.
Authority
					 G.S.
					 97-22;
					 97-24;
					 97-58;
					 97-80(a);
					 97-81;
Eff. January 1,
					 1990;
Amended Eff. November 1, 2014;
Recodified from
					 04 NCAC
					 10A .0103 Eff. June 1, 2018;
Amended Eff. December 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter A - WORKERS' COMPENSATION RULES › Section .0100 - ADMINISTRATION › Section 23A .0104 - EMPLOYER'S REQUIREMENT TO FILE FIRST REPORT OF INJURY

Current through Register Vol. 39, No. 2, July 15, 2024
(a)
				  The form required to be provided by
				  G.S.
				  97-92(a) is the Form 19
				  Employer's Report of Employee's Injury or Occupational Disease to the
				  Industrial Commission. The Form 19 shall be used when the injury causes the
				  employee to be absent from work for more than one day or when the charges for
				  medical compensation exceed four thousand dollars ($4,000). The Form 19 shall
				  be filed with the Commission in accordance with Rule .0108(d) of this
				  Section.
(b) The employer, carrier,
				  or administrator shall provide the employee with a copy of the completed Form
				  19 Employer's Report of Employee's Injury or Occupational Disease to the
				  Industrial Commission, along with a blank Form 18 Notice of Accident to
				  Employer and Claim of Employee, Representative, or Dependent for use by the
				  employee in making a claim.
Authority
					 G.S.
					 97-80(a);
					 97-92;
Eff. March 15,
					 1995;
Amended Eff. November 1, 2014; January 1, 2011; August 1,
					 2006; March 1, 2001; June 1, 2000;
Recodified from
					 04 NCAC
					 10A .0104 Eff. June 1, 2018;
Amended Eff. December 1, 2020.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter A - WORKERS' COMPENSATION RULES › Section .0100 - ADMINISTRATION › Section 23A .0105 - ELECTRONIC PAYMENT OF COSTS

Current through Register Vol. 39, No. 2, July 15, 2024
Authority
					 G.S.
					 97-80(a);
Eff.
					 January 1, 2011;
Rule Expired July 18, 2013 (see S.L. 2013-294, s.
					 1);
Recodified from
					 04 NCAC
					 10A .0105 Eff. June 1,
					 2018.