Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0320 - Provider contracts-Standards-Hold harmless provisions

Current through Register Vol. 24-14, July 15, 2024
The execution of a contract by an issuer does not relieve
				  the issuer of its obligations to any enrollee for the provision of health care
				  services, nor of its responsibility for compliance with statutes or
				  regulations. In addition to the contract form filing requirements of this
				  sub-chapter, all individual provider and facility contracts must be in writing
				  and available for review upon request by the commissioner.
(1) An issuer must establish a mechanism by
				which its participating providers and facilities can obtain timely information
				on patient eligibility for health care services and health plan benefits,
				including any limitations or conditions on services or benefits.
(2) Nothing contained in a participating
				provider or a participating facility contract may have the effect of modifying
				benefits, terms, or conditions contained in the health plan. In the event of
				any conflict between the contract and a health plan, the benefits, terms, and
				conditions of the health plan must govern with respect to coverage provided to
				enrollees.
(3) Each participating
				provider and participating facility contract must contain the following
				provisions:
(a) {Name of provider or
				facility} hereby agrees that in no event, including, but not limited to
				nonpayment by {name of issuer}, {name of issuer's} insolvency, or breach of
				this contract will {name of provider or facility} bill, charge, collect a
				deposit from, seek compensation, remuneration, or reimbursement from, or have
				any recourse against an enrollee or person acting on their behalf, other than
				{name of issuer}, for services provided pursuant to this contract. This
				provision does not prohibit collection of {deductibles, copayments,
				coinsurance, and/or payment for noncovered services}, which have not otherwise
				been paid by a primary or secondary issuer in accordance with regulatory
				standards for coordination of benefits, from enrollees in accordance with the
				terms of the enrollee's health plan.
(b) {Name of provider or facility} agrees, in
				the event of {name of issuer's} insolvency, to continue to provide the services
				promised in this contract to enrollees of {name of issuer} for the duration of
				the period for which premiums on behalf of the enrollee were paid to {Name of
				issuer} or until the enrollee's discharge from inpatient facilities, whichever
				time is greater.
(c)
				Notwithstanding any other provision of this contract, nothing in this contract
				shall be construed to modify the rights and benefits contained in the
				enrollee's health plan.
(d) {Name
				of provider or facility} may not bill the enrollee for covered services (except
				for deductibles, copayments, or coinsurance) where {name of issuer} denies
				payments because the provider or facility has failed to comply with the terms
				or conditions of this contract.
(e)
				{Name of provider or facility} further agrees (i) that the provisions of (a),
				(b), (c), and (d) of this subsection shall survive termination of this contract
				regardless of the cause giving rise to termination and shall be construed to be
				for the benefit of {name of issuer's} enrollees, and (ii) that this provision
				supersedes any oral or written contrary agreement now existing or hereafter
				entered into between {name of provider or facility} and enrollees or persons
				acting on their behalf.
(f) If
				{name of provider or facility} contracts with other providers or facilities who
				agree to provide covered services to enrollees of {name of issuer} with the
				expectation of receiving payment directly or indirectly from {name of issuer},
				such providers or facilities must agree to abide by the provisions of (a), (b),
				(c), (d), and (e) of this subsection."