|
REFERENCE TITLE: AHCCCS; third-party coverage; cost avoidance |
|
State of Arizona House of Representatives Forty-ninth Legislature Second Regular Session 2010
|
|
HB 2497 |
|
|
|
Introduced by Representatives Seel: Lesko
|
AN ACT
Amending title 36, chapter 29, article 1, Arizona Revised Statutes, by adding section 36-2905.03; relating to the Arizona health care cost containment system.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Title 36, chapter 29, article 1, Arizona Revised Statutes, is amended by adding section 36-2905.03, to read:
36-2905.03. Third-party coverage; cost avoidance; certification of primacy; civil penalty; license revocation; audit; request for proposal
A. All entities that provide health insurance or health care coverage to residents of this state must respond to eligibility inquiry messages or upload to a centralized database information on coverage and benefits as the administration may require regarding the coverage that entity provides to any patient or beneficiary.
B. The administration shall presume that coverage may exist for members who are enrolled pursuant to this chapter on the enrollment record of any other health plan and shall cause eligibility inquiries to be transmitted to every health plan or health insurer in the United States, for their respective classes of claims.
C. Beginning October 1, 2010, the administration may not pay for services for a specific member unless it has certified the administration's primacy derived from a comprehensive, electronic, preemptive test of all other coverage for that member.
D. To establish the coverage in force for a member, the administration may transmit the minimum human identifiers in the ANSI X.12 270 standard for eligibility inquiries, including the patient's name, sex and date of birth, to all entities licensed or registered to provide health insurance or health care coverage to individuals who reside in this state. To ensure rapid response and eliminate any delay in the payment of legitimate claims by public entities, a health plan receiving such messages must respond accurately to them within twenty-four hours.
E. The administration has a cause of action for injunctive relief and costs, including attorney fees, for the enforcement of this section against any noncompliant health plan. On a second or subsequent occurrence of failure or refusal to reply to the messages as required by this section, the court shall award the plaintiff damages pursuant to subsection F.
F. On a finding that a health plan knowingly failed or refused to comply with the duties imposed by this section, a court shall impose a civil penalty of one thousand dollars for each eligibility message the entity failed or refused to reply to as required by this section. An attempt to impose data elements or other burdens not expressly authorized by this section on the content, terms or execution of messaging is a refusal to comply with the requirements of this section.
G. On a showing by the administration that a health plan has failed or refused to respond to the messaging requirements of this section, the attorney general shall:
1. Subpoena the noncompliant entity's enrollment data.
2. Commence a complaint under 42 United States Code section 1320d‑5 for administrative sanctions.
3. Commence a prosecution under 18 United States Code section 1035.
4. Commence an action in state court to enjoin the entity from nonperformance of its duty under this section.
H. On notice of a second finding of an entity's failure or refusal to comply with the messaging requirements of this section, the department of insurance shall permanently revoke that entity's license. The department shall include any finding by another state's health plan or provider or by the federal government of a violation of comparable law in the calculation of first and second offenses.
I. On or before July 1 of each year, the administration shall conduct an audit of the primacy of its payments by matching the identities of its members electronically using the transactions mandated pursuant to 42 United States Code section 1320d against the enrollment of all other health plans. The administration must file the results of its audit with the department of insurance on or before September 1 of each year.
J. Eligibility coverage data that is shared pursuant to this section by health plans and other parties in the process of determining primacy is an element of data used in the process of billing for medical services rendered, and is expressly exempt from the privacy and confidentiality provisions of 42 United States Code section 1320d and state law. A person who receives this data for that purpose may not convert the use of that data to any other purpose.
K. The administration shall award a contract pursuant to a public request for proposal for a system that will assist the administration to implement the cost avoidance provisions of this section by identifying the source of existing insurance coverage for members.