Health insurance; provider contracts, business practices, penalties.

Health insurance; provider contracts; business practices;penalties. Provides that amendments to a provider contract or any materialprovision, addenda, schedule, exhibit, or policy thereto, as it relates to anymaterial provision that was agreed to or accepted by the provider in theprevious 12-month period, or that occurred during the current term of theprovider contract and resulted in an adverse change, are not effective unlessagreed to by the provider in writing. The measure requires such an amendment tobe agreed to by the provider in a signed written amendment to the providercontract. The measure defines a material provision of a provider contract asany policy manual, coverage guideline, edit, multiple procedure logic, or auditprocedure that (i) decreases the provider's payment or compensation, (ii)limits an enrollee's access to covered services under his health plan, or (iii)changes the administrative procedures applicable to a provider contract in away that may reasonably be expected to significantly increase the provider'sadministrative expense. The measure requires carriers to permit a provider todetermine the carrier's policies regarding the use of edits or multipleprocedure logic. The measure requires carriers to provide, for each health planin which the provider participates or is proposed to participate, a completefee schedule for all health care services included under the provider contractwith the provider in writing and to make such fee schedules available inmachine-readable electronic format. The measure requires a provider contract topermit a provider a minimum of one year from the date a health care service isrendered to submit a claim for payment, unless otherwise agreed upon. Themeasure also (a) requires the State Corporation Commission to assist providersand to examine and investigate provider complaints and inquiries relating to analleged or suspected failure by a carrier to comply with required minimum fairbusiness standards, (b) requires the Commission to provide a determination ofwhether a carrier has failed to comply with these standards within 60 days ofreceipt of a provider's complaint or inquiry, (c) authorizes the Commission todetermine whether a carrier's practices comply with these standards, (d)subjects a person that refuses or fails to provide information in a timelymanner to the Commission to enforcement and penalty provisions, and (e)authorizes the Commission to impose penalties or issue a cease and desist orderto a carrier that fails to comply with these standards.