 |
ARIZONA STATE SENATE
Fifty-Fifth Legislature, First Regular Session
health insurers; provider network; denial
Purpose
Requires a health care insurer (insurer) to give a health care provider (provider), if the insurer denies the provider's request to join the insurer's provider network, a written response that explains the basis of the denial and instructions on how to file an appeal of the denial.
Background
Enacted in 2010, the Affordable Care Act requires that all qualified health plans include an adequate network of primary care providers, specialists and other ancillary health care providers. The Secretary of the U.S. Department of Health and Human Services must establish criteria for the certification of qualified health plans to be offered on a state's health insurance exchange, including requirements to ensure sufficient choice of providers and essential community providers in accordance with federal law. A group health plan and a health insurance issuer offering group or individual health insurance coverage must not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable state law. A group health plan or health insurance issuer is not required to contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer (P.L. 111-148, 111th Congress, 2010).
There is no anticipated fiscal impact to the state General Fund associated with this legislation.
Provisions
1. Requires an insurer, if the insurer denies a provider's request to join the insurer's provider network, to give the provider a written response that includes:
a) an explanation of the basis of the denial;
b) the specific terms and conditions that the insurer believes the provider does not satisfy;
c) the specific terms and conditions with which the provider must comply to be allowed to join the insurer's provider network; and
d) detailed instructions that explain the process to follow to file an appeal of the denial.
2. Prohibits an insurer from denying a request to join the insurer's provider network based solely on the insurer's perception that additional network providers are not needed.
3. Defines health care insurer as any of the following entities that provide coverage for health care services delivered by a provider network:
a) disability insurer;
b) group disability insurer;
c) blanket disability insurer;
d) health care services organization;
e) hospital service corporation;
f) medical service corporation;
g) dental service corporation;
h) optometric service corporation; and
i) hospital, medical, dental and optometric service corporation.
4. Defines health care provider as an individual or entity that is licensed, registered, permitted or certified as a health care professional or entity under A.R.S. Title 32 or Title 36 and that provides health care services, medical services, nursing services or other health-related services to patients.
5. Defines provider network as a defined set of health care providers under contract with a health care insurer to deliver health care services to persons who are covered under the health care insurer's health care plan.
6. Becomes effective on the general effective date.
Prepared by Senate Research
February 15, 2021
MG/ML/gs