PURPOSE: This rule implements and interprets the provisions of section 376.427, RSMo.

1. (1) Definitions. For the purpose of this regulation—

   1. (A) Assignment means any written authorization by an insured directed to an insurer instructing the insurer to pay benefits for health care services to the provider of services;
   2. (B) Claim means proof of claim forms, bills, itemized charges and all other documents reasonably required by an insurer to investigate, adjust and pay benefits pursuant to the terms of a contract;
   3. (C) Contract means an individual or group health insurance policy or contract which provides coverage on an expense-incurred basis and is issued by an insurer doing business in Missouri;
   4. (D) Health care services means medical, surgical, dental, podiatric, pharmaceutical, chiropractic, licensed ambulance service and optometric services;
   5. (E) Insured means any person entitled to benefits under a contract issued by an insurer;
   6. (F) Insurer means any insurance company issuing or writing any policy of accident and sickness insurance and any health services corporation subject to the provisions of sections 354.010–354.380, RSMo; and
   7. (G) Provider means a physician, hospital, dentist, podiatrist, chiropractor, pharmacy, licensed ambulance service or optometrist licensed by this state.
2. (2) Upon receipt of an assignment of benefits made by the insured to a provider, an insurer subject to the provisions of section 376.427.1(3), RSMo and not excluded pursuant to the provisions of section 376.427.4, RSMo shall issue the instrument for payment of the benefits for health care services in the name of the provider.
3. (3) All payments shall be made within thirty
4. (30) days of the receipt by the insurer of all documents reasonably needed to adjudicate the claim.
5. (4) All contracts shall contain a provision stating that benefits payable under the contract shall be paid, with or without an assignment of benefits from the insured, to public hospitals and clinics for health care services and supplies provided to the insured if a proper claim is submitted by the public hospital or clinic as specified in section 376.778.2, RSMo and if benefits have not been paid to the insured prior to receipt of the claim by the insurer. Payment of benefits to the public hospital or clinic by the insurer shall discharge the insurer from all liability to the insured to the extent of benefits paid. Under no circumstances, however, shall payment of duplicate benefits to both the insured and the public hospital or clinic for the same services or supplies be required.

AUTHORITY: sections 374.045 and 376.778, RSMo 1986 and 376.427, RSMo Supp. 1990.* Original rule filed April 25, 1991, effective Sept. 30, 1991.

*Original authority: 374.045, RSMo 1967; 376.778, RSMo 1983; and 376.427, RSMo 1990.