(a) If a healthcare insurer does not have a participating provider who provides a breast reconstruction surgery that has been determined as the best course of treatment by a healthcare professional and is consistent with prevailing medical standards and in consultation with the patient, then the healthcare insurer shall reimburse the out-of-network provider who performs the breast reconstruction surgery at an amount that is the lesser of:(1) The healthcare professional's billed charges for the healthcare services; or(2) The eightieth percentile of all charges for the particular healthcare service performed by a healthcare professional in the same or similar specialty and provided in the same or similar geographical area as reported in a benchmarking database that is maintained by a nonprofit organization if that nonprofit organization is not affiliated with, financially supported by, or otherwise supported by a healthcare insurer.
(1) The healthcare professional's billed charges for the healthcare services; or
(2) The eightieth percentile of all charges for the particular healthcare service performed by a healthcare professional in the same or similar specialty and provided in the same or similar geographical area as reported in a benchmarking database that is maintained by a nonprofit organization if that nonprofit organization is not affiliated with, financially supported by, or otherwise supported by a healthcare insurer.
(b) A healthcare insurer shall provide a fair and reasonable facility reimbursement rate for healthcare services performed by a healthcare professional in a healthcare facility under this subchapter.
(c) (1) In the case of a healthcare insurer that does not reimburse an out-of-network provider or a healthcare facility as required under this section, the healthcare insurer, in addition to making the required payment for the healthcare services, shall pay the out-of-network provider or healthcare facility an amount that is three (3) times the difference between:(A) The initial payment, or in the case of a notice of denial of payment, zero dollars ($0.00); and(B) The out-of-network reimbursement rate required under this section, less any cost-sharing required to be paid by the enrollee.(2) The payment that is required under subdivision (c)(1) of this section is subject to interest in a manner specified by the Insurance Commissioner by rule.
(1) In the case of a healthcare insurer that does not reimburse an out-of-network provider or a healthcare facility as required under this section, the healthcare insurer, in addition to making the required payment for the healthcare services, shall pay the out-of-network provider or healthcare facility an amount that is three (3) times the difference between:(A) The initial payment, or in the case of a notice of denial of payment, zero dollars ($0.00); and(B) The out-of-network reimbursement rate required under this section, less any cost-sharing required to be paid by the enrollee.
(A) The initial payment, or in the case of a notice of denial of payment, zero dollars ($0.00); and
(B) The out-of-network reimbursement rate required under this section, less any cost-sharing required to be paid by the enrollee.
(2) The payment that is required under subdivision (c)(1) of this section is subject to interest in a manner specified by the Insurance Commissioner by rule.