02-031 C.M.R. ch. 790
| Section 1. | Purpose and Scope |
|---|---|
| Section 2. | Definitions |
| Section 3. | Information Sharing |
| Section 4. | Interim Dispute Resolution |
| Section 5. | Severability |
| Section 6. | Effective Date |
This Rule is adopted by the Superintendent, pursuant to 24 M.R.S.A. § 2332-A and 24-A M.R.S.A. §§ 212, 2723-A, 2844, and 4218, in order to provide for the orderly transfer of information needed to pay claims promptly and reduce claims payment delays and misunderstandings. This Rule applies to all health carriers and other entities subject to the jurisdiction of the Superintendent of Insurance.
The following terms, when used in this Rule, shall have the following meanings unless the context clearly indicates otherwise:
A. “Coordination of benefits provision” or “COB provision” means a contractual provision that establishes an order in which plans intend to pay their claims, and describes how benefits provided by the plan will be calculated when the plan is secondary to avoid duplication of payment.
B. “Carrier” means an insurer, a health maintenance organization, a preferred provider arrangement administrator, a fraternal benefit society, a nonprofit hospital or medical service organization or health plan, a multiple-employer welfare arrangement, or a self-insured employer subject to state regulation as described in 24-A M.R.S.A. § 2848-A.
C. “Plan” means a health benefit plan issued or administered by a carrier.
D. “Primary plan” means a plan whose benefits for a person’s health care coverage must be determined before taking the existence of any other plan into consideration.
E. “Secondary plan” means a plan which is not a Primary Plan.
A. General. A carrier whose plan contains a coordination of benefits or COB provision may require covered persons to disclose whether they are covered by other plans and to provide sufficient information to determine which plan is primary. A secondary plan may require a covered person to claim benefits under the primary plan as a condition of coverage under the secondary plan.
B. Streamlined Benefit Administration. Carriers are encouraged to develop procedures for coordinating claims processing when claimants are insured by multiple plans and reimbursement from another carrier is known to be available.
C. Information Sharing. Each carrier shall provide to any other carrier with which it seeks to coordinate benefits, to any carrier which seeks information to determine whether it has a right to coordinate benefits with it, any information it acquires that the other carrier needs or may consider relevant to determining priority of payment. Relevant information includes, but is not limited to, the identity of other carriers and plans and the identity of a claimant's custodial parent. Such information must be provided promptly after receiving a request to provide information to the other carrier and receiving complete information from the claimant.
D. Suspension of filing deadlines. Submission of a timely claim to one carrier when there is multiple coverage shall suspend all other applicable filing deadlines for a minimum of 120 days after that carrier has adjudicated the claim, as long as the claimant provides all information requested by all carriers within a reasonable time after the request.
A. The interim dispute resolution requirements of this Rule apply to the following types of health plans:
(1) All health insurance policies; nonprofit hospital, medical, or health service contracts; and similar health coverage contracts, whether offered on a group basis or on an individual, family, blanket, or "nongroup" basis;
(2) Coverage through health maintenance organizations;
(3) The medical payments coverage in automobile insurance policies; and
(4) Self-insured plans subject to state regulation as described in 24-A M.R.S.A, § 2848-A.
B. Interim Payment. If the carriers cannot agree on the order of benefits within thirty (30) calendar days after the carriers have received all of the information needed to pay the claim and determine the order of benefits, the carriers shall immediately pay the claim in equal shares and determine their relative liabilities following payment, except that no carrier shall be required to pay more than it would have paid had it been primary.
C. Noncomplying Plans. If the primary plan is not subject to the jurisdiction of the Superintendent and the primary carrier refuses to pay the full amount for which it is responsible, the secondary carrier shall pay the remainder on a provisional basis, up to the
additional amount for which it would be responsible if its plan were primary, without prejudice to any right it might have to recover that amount from the primary carrier in another forum. The carrier issuing the complying plan shall be subrogated to the rights of the employee, subscriber, or member under the noncomplying plan on a just and equitable basis, consistent with 24-A M.R.S.A. §§ 2729-A, 2836 and 4243. The same procedure shall apply if the Superintendent has jurisdiction over the primary plan but is compelled by applicable choice-of-law principles to permit the primary plan to pay as a secondary plan. As a condition of its provisional payment obligation under this Subsection, the carrier may require the employee, subscriber, or member to provide written approval of the carrier’s subrogation right.
If any section, term, provision, or application of this Rule is adjudged invalid for any reason, such judgment shall not impair or invalidate any other section, term, provision, or application, and the remainder of this Rule shall continue in full force and effect.
This Rule is effective June 29, 2004.
STATUTORY AUTHORITY: 24 M.R.S.A. §2332-A, 24-A M.R.S.A. §§ 212, 2723-A, 2844 and 4218
EFFECTIVE DATE:
June 29, 2004 - filing 2004-237