Title 20 — Insurance

1. Discriminate in reimbursement on the basis that the pharmacy dispenses a 340B drug. 2. Assess any fee, chargeback, clawback or adjustment on the basis that a pharmacy dispenses a 340B drug. 3. Exclude a pharmacy from a third party's pharmacy network on the basis that the pharm…

In this article, unless the context otherwise requires: 1. "Adverse determination": (a) Means a decision by a health care services plan or its utilization review agent that the health care services furnished or proposed to be furnished to an enrollee are not medically necessary a…

A. A health care services plan or its utilization review agent may impose a prior authorization requirement for health care services provided to an enrollee, except for emergency ambulance services and emergency services as specified in section 20-2803, health care services arisi…

A. If a health care services plan contains a prior authorization requirement, all of the following apply: 1. The health care services plan or its utilization review agent shall make available to all providers on its website or provider portal a listing of all prior authorization …

A. If a plan offered by a health care services plan contains a prior authorization requirement, all of the following apply: 1. For prior authorization requests concerning urgent health care services, the health care services plan or its utilization review agent shall notify the p…

A. For a prior authorization request related to a chronic pain condition, the health care services plan or its utilization review agent shall honor a prior authorization that is granted for an approved prescription drug for the earliest of the following: 1. Six months after the d…

1. Not exceed two printed pages. This two-page limit does not apply to or include a provider's notes or documentation that the provider submits in support of a prior authorization request. 2. Meet the electronic submission and acceptance requirements prescribed in section 20-3403…

(Eff. 7/1/26) Before a health care insurer may issue a direct denial of a prior authorization of a service that was requested by a provider and that involves medical necessity, the medical director shall individually review the denial. During each individual review, the medical d…

In this chapter, unless the context otherwise requires: 1. "Applicant" means a provider that submits a credentialing application to a health insurer to become a participating provider in the health insurer's network. 2. "Application" means an applicant's initial application to be…

A. A health insurer shall establish a process for the electronic submission of a credentialing application. On or before December 31, 2019, the health insurers shall adopt and implement a standard application. B. On or before December 31, 2019, to the greatest extent possible, a …

A. Except as provided in subsection C of this section, the health insurer shall conclude the process of credentialing within sixty calendar days and loading the applicant's information into the health insurer's billing system within thirty calendar days after the date the health …

A. When submitting a credentialing application, a health insurer shall provide written or electronic acknowledgement to an applicant within seven calendar days after the health insurer's receipt of the application. The applicant shall include in the application a contact name, te…

A health insurer shall take reasonable steps to correct discrepancies in the provider or network plan directory within thirty calendar days after receiving a written or electronic report of the discrepancy from a participating provider. A participating provider shall notify a hea…

A. A provider may receive payment from a health insurer pursuant to this section for services that were provided from the date that was included on the notice of complete credentialing application to the date the provider's network participation contract is executed. A health ins…

1. The applicable credentialing policies and procedures. 2. A list of all the information required to be included in an application. 3. A checklist of materials that must be submitted in the credentialing process. 4. Designated contact information, including a designated point of…

B. A participating provider remains credentialed and loaded in the health insurer's billing system unless the health insurer discovers information that would result in the participating provider ceasing to meet the health insurer's guidelines for participation, in which case the …

A. A health insurer that complies in good faith with the requirements of this chapter is immune from civil liability for the purposes of reviewing and approving a credentialing application. B. A health insurer that does not credential a provider is not subject to civil liability …

1. "Classification of benefits" means the following classifications of benefits provided by a health plan: (a) Inpatient, in-network. (b) Inpatient, out-of-network. (c) Outpatient, in-network. (d) Outpatient, out-of-network. (e) Emergency care. (f) Prescription benefits. 2. "Heal…

B. After January 1, 2022, on a date specified by the director, each health care insurer that issues a health plan in this state shall submit a report to the department for each fully insured product network type the health care insurer issues. If the health care insurer determine…

B. On or before January 1, 2021, the department shall develop a web page that provides the following information in nontechnical and readily understandable language: 1. Consumer-friendly information concerning the scope and applicability of the mental health parity and addiction …

B. This section does not require a health care insurer to approve a claim or provide reimbursement for a mental health or substance use disorder service provided by an out-of-network provider except as allowed by the health plan that covers the subscriber, enrollee or insured. C.…

1. Four members who represent health care insurers. 2. One member who is a licensed behavioral health services provider. 3. One member who represents a behavioral health advocacy organization. 4. At least three members or family members who are not employed by or contracted with …

1. "Aggregator site" means a website that provides access to information regarding insurance products from more than one insurer, including product and insurer information, for use in comparison shopping. 2. "Blanket travel insurance" means a policy of travel insurance that is is…

B. The requirements of this chapter apply to travel insurance that covers any resident of this state and that is sold, solicited, negotiated or offered in this state and to policies and certificates that are delivered or issued for delivery in this state. This chapter does not ap…

1. The limited lines travel insurance producer or travel retailer provides to purchasers of travel insurance all of the following: (a) A description of the material terms or the actual material terms of the insurance coverage. (b) A description of the process for filing a claim. …

1. An individual primary policyholder who is a resident of this state. 2. A primary certificate holder who is a resident of this state and who elects coverage under a group travel insurance policy. 3. A blanket travel insurance policyholder that is a resident in this state, or ha…

1. The travel protection plan clearly discloses to the consumer, at or before the time of purchase, that it includes travel insurance, travel assistance services and cancellation fee waivers, as applicable, and provides information and an opportunity, at or before the time of pur…

B. Offering or selling a travel insurance policy that could never result in payment of any claims for any insured under the policy is an unfair trade practice under chapter 2, article 6 of this title. C. All documents provided to consumers before the purchase of travel insurance,…

1. Is a licensed property and casualty insurance producer in this state for activities allowed under that producer license. 2. Holds a valid managing general agent license in this state. B. A travel administrator and its employees are exempt from the licensing requirements of cha…

B. Travel insurance may be in the form of an individual, group or blanket policy. C. Eligibility and underwriting standards for travel insurance may be developed and provided based on travel protection plans that are designed for individual or identified marketing or distribution…

1. Is: (a) Organized or, in the case of a United States office of a foreign banking organization, is licensed under the laws of the United States or any state of the United States. (b) Regulated, supervised and examined by United States federal or state authorities having regulat…

1. The valuation of assets or reserve credits. 2. The amount and forms of security supporting reinsurance arrangements described in section 20-3603, subsection B. 3. The circumstances pursuant to which credit will be reduced or eliminated. B. Credit shall be allowed under subsect…

1. The valuation of assets or reserve credits. 2. The amount and forms of security supporting reinsurance arrangements described in subsection B of this section. 3. The circumstances pursuant to which credit will be reduced or eliminated. B. The reduction shall be in the amount o…

B. The rules may include regulation of reinsurance arrangements relating to any of the following: 1. Life insurance policies with guaranteed nonlevel gross premiums or guaranteed nonlevel benefits. 2. Universal life insurance policies with provisions resulting in the ability of a…

[Repealed or reserved.]

1. "Clinical practice guidelines" means a systematically developed statement to assist health care providers and patients in making decisions about appropriate health care for specific clinical circumstances and conditions. 2. "Clinical review criteria" means the written screenin…

1. Any health care plan that is subject to state law regulating insurance, that provides prescription drug benefits and that includes coverage for a step therapy protocol regardless of how that coverage is described. 2. A contractor, agent or similar entity that implements covera…

1. Recommend that the prescription drugs be taken in the specific sequence required by the step therapy protocol. 2. Except as provided in subsection B of this section, are developed and endorsed by a multidisciplinary panel of experts that manages conflicts of interest among the…

B. A step therapy exception request shall be granted if sufficient justification and any necessary supporting clinical documentation are submitted to establish that any of the following applies: 1. The prescription drug required by the step therapy protocol is contraindicated or …