North Carolina Administrative Code

11 NCAC 12 .1506 ELECTRONIC FORMAT STANDARDS (a) As used in this Rule, "ASC X12 Standard Format" means the standards for electronic data interchange within the health care provider industry developed by the Accredited Standards Committee X12 Insurance Subcommittee of the American…

11 NCAC 12 .1507 ATTACHMENT FORM OR FORMAT (a) As used in this Rule, "attachment form or format" means a form, document, or communication of any kind used by a payor to request additional information, other than that contained on the standard claim form, from a health care provid…

11 NCAC 12 .1508 MEDICARE SUPPLEMENT PAYORS Medicare supplement insurance payors shall electronically interface claims data with the Medicare Section of CMS. History Note: Authority G.S. 58-2-40; 58-3-171; Eff. October 1, 1994; Readopted Eff. May 1, 2020.

11 NCAC 12 .1509 PATIENT SUBMITTED CLAIM FORMS The health care provider shall provide a patient the CMS-1500 and UB-04 (CMS-1450) standard claim forms, if the patient must submit a claim to a payor. The standard claim form shall be provided as the initial bill for payment of serv…

SECTION .1600 - RETAINED ASSET ACCOUNTS 11 NCAC 12 .1601 DEFINITIONS As used in this Section: (1) "Policy" means any policy or certificate of insurance that provides a death benefit. (2) "Retained asset account" or "account" means any mechanism whereby the settlement of proceeds …

11 NCAC 12 .1602 GENERAL REQUIREMENTS No insurer shall offer retained asset accounts as a mode of settlement of proceeds unless the insurer complies with the following: (1) The retained asset account shall be specifically identified as a settlement option within the terms of the …

11 NCAC 12 .1603 DISCLOSURE REQUIREMENTS In conjunction with the use of a retained asset account as a mode of settlement, the insurer shall disclose the following, in writing, to any beneficiary or, in the case of a group contract, to the policy owner: (1) Any other settlement op…

11 NCAC 12 .1604 ACCOUNTING Funds necessary to cover liabilities under retained asset accounts shall be reported on the annual statement. History Note: Authority G.S. 58-2-40; 58-2-165; 58-58-1; 58-58-110; Eff. February 1, 1996; Pursuant to G.S. 150B-21.3A, rule is necessary with…

11 NCAC 12 .1710 DEFINITIONS (a) The definitions contained in G.S. 58-58-205 apply to this Section. (b) The following definitions shall apply to this Section: (1) "Division" means the Life and Health Division of the Department of Insurance. (2) "Insured" means the person covered …

11 NCAC 12 .1711 license requirements (a) In addition to the information required by G.S. 58-58-210, applicants for provider licenses shall submit the following: (1) A plan of operation, including the manner in which the provider proposes to operate in North Carolina and the type…

11 NCAC 12 .1712 Viatical settlement brokers (a) Applications for broker licenses shall be made with the Agent Services Division of the Department of Insurance. (b) A broker shall not, without the written agreement of the viator obtained before performing any services in connecti…

11 NCAC 12 .1713 Standards for evaluation of reasonable payments (a) Insureds who are terminally or chronically ill shall receive no less than the following payouts for viaticating a policy. The percentage may be reduced by 5% for viaticating a policy written by an insurer rated …

11 NCAC 12 .1714 Reporting requirements (a) On June 1 of each calendar year, each licensed provider shall make a report of all viatical settlement transactions in which the viators are residents of this State. The report shall contain the following information for the previous ca…

11 NCAC 12 .1715 General rules (a) With respect to a policy containing a provision for double or additional indemnity for accidental death, the additional payment shall remain payable to the beneficiary last named by the viator before entering into the viatical settlement contrac…

11 NCAC 12 .1716 CONTRACTS AND PAYMENT OF PROCEEDS (a) Two specimen copies of each contract, application, brochure, and proposal shall be filed with the Division for approval under G.S. 58-58-220. (b) In addition to the requirements in G.S. 58-58-250, every contract shall include…

11 NCAC 12 .1717 advertising MATERIAL History Note: Authority G.S. 58-2-40; 58-58-220; 58-58-300; Temporary Adoption Eff. April 1, 2002; Temporary Adoption Expired December 27, 2002.

11 NCAC 12 .1718 disclosure (a) The provider, upon receipt of an application to viaticate and after determining the value to be offered in return for the assignment or transfer of the death benefit or ownership of a policy to the provider, shall deliver a proposal to the viator b…

11 NCAC 12 .1719 prohibited practices (a) A provider or broker shall obtain from a person that is provided with patient identifying information a signed affirmation that the person or entity will not further divulge the information without procuring the express, written consent o…

11 NCAC 12 .1720 insurance company practices (a) Every life insurance company licensed in this State shall respond to a request for verification of coverage from a provider or a broker within 30 calendar days after the date a request is received. The insurer shall inform the prov…

SECTION .1800 - PPO BENEFIT PLAN PRODUCT LIMITATIONS 11 NCAC 12 .1801 APPLICABILITY This Section applies to any insurer or service corporation that, under G.S. 58-50-56, offers a preferred provider benefit plan. History Note: Authority G.S. 58-2-40; 58-50-56; Temporary Adoption E…

11 NCAC 12 .1802 DEFINITIONS The definitions contained in G.S. 58-50-56(a) are incorporated into this Section by reference and as used in this Section, the following terms have the meanings ascribed to them: (1) "Coinsurance" means the percentage of an allowed charge or expense, …

11 NCAC 12 .1803 GENERAL REQUIREMENTS No insurer shall provide any PPO benefit plan unless it complies with the following: (1) Where the covered benefits of a PPO benefit plan include coinsurance, the difference in coinsurance rates between in-network covered services and out-of-…

11 NCAC 12 .1804 DISCLOSURE REQUIREMENTS (a) If an enrollee utilizes out-of-network covered services, the explanation of benefits shall contain an explanation of coverage for out-of-network covered services that allows each enrollee to determine his or her obligations with respec…

Section .1900 – domestic violence – prohibited acts 11 NCAC 12 .1901 DEFINITIONS As used in this Section, the following terms have the meanings ascribed to them: (1) "Abuse" means the occurrence of one or more of the following acts by a current or former family member, household …

11 NCAC 12 .1902 UNFAIR OR DECEPTIVE ACTS OR PRACTICES (a) The following are unfair or deceptive acts or practices in the business of insurance: (1) To deny, refuse to issue, renew or reissue, cancel or otherwise terminate a health benefit plan, or restrict or exclude health bene…

11 NCAC 12 .1903 JUSTIFICATION OF ADVERSE INSURANCE DECISIONS An insurer or insurance professional that takes an action that adversely affects an applicant or insured on the basis of a medical condition that the health insurer or insurance professional knows or has reason to know…

11 NCAC 13 .0222 PROHIBITED EMPLOYMENT PRACTICES History Note: Authority G.S. 66-46; Eff. January 1, 1978; Repealed Eff. July 1, 1988.

SECTION .0300 - INSURANCE PREMIUM FINANCE COMPANIES 11 NCAC 13 .0301 FORMS The following forms are provided by the division and are used by insurance premium finance companies for purposes as specified herein: (1) Application for Insurance Premium Finance License. The form entitl…

11 NCAC 13 .0302 PREMIUM FINANCE SURETY BOND AMOUNT An "A" type premium finance company, as defined in G.S. 58-35-5(e)(1), shall post the surety bond as specified in G.S. 58-35-15(a) in an amount equal to one thousand dollars ($1,000) for each five thousand dollars ($5,000) in pr…

11 NCAC 13 .0303 PREMIUM FINANCE LICENSING PROCEDURES (a) Applicants must meet minimum qualifications as stated in G.S. 58, Article 35. (b) Applicants must submit a properly completed "Application for Insurance Premium Finance License" to the Division. The following items, where …

11 NCAC 13 .0304 RENEWAL OF INSURANCE PREMIUM FINANCE LICENSE History Note: Authority G.S. 58-2-40; 58-35-15(c); Eff. February 1, 1976; Readopted Eff. January 1, 1978; Amended Eff. April 8, 2002; Repealed Eff. October 1, 2010.

11 NCAC 13 .0305 CANCELLATION OF SURETY BOND If the surety bond as specified in G.S. 58-35-15(a) is cancelled for any reason during the period a premium finance company holds a valid license from the Department, the licensee shall be notified in writing by the Commissioner that i…

11 NCAC 13 .0306 FORMS TO BE APPROVED All ten-day notices of intent to cancel forms, cancellation notices, additional premium notices, premium finance agreement revision notices, or all other notices or forms mailed or given to North Carolina insureds shall be filed with the Comm…

11 NCAC 13 .0307 CHANGE IN OWNERSHIP OR MANAGEMENT AND IN CERTAIN EMPLOYEES Each licensee shall furnish all the following information in writing to the Commissioner within 10 days after the occurrence of the event: (1) form DOI-5PF on each stockholder who attains ten percent or m…

11 NCAC 13 .0308 analysis of contracts Each person licensed by the North Carolina Department of Insurance under G.S. 58-35-15 shall file a regular report entitled "Analysis of Contracts" with the Commissioner along with the annual renewal application required by G.S. 58-35-15(c).…

11 NCAC 13 .0309 QUARTERLY REPORT History Note: Authority G.S. 58-2-40; 58-35-30; Eff. February 1, 1976; Readopted Eff. January 1, 1978; Amended Eff. May 1, 1989; Repealed Eff. October 1, 2010.

11 NCAC 13 .0310 BOOKS AND RECORDS Each licensee shall keep and maintain the following records, separate and apart from any other business, so as to be readily available for inspection by the Commissioner, or an employee designated by the Commissioner: (1) a copy of each premium …

11 NCAC 13 .0311 BRANCH OFFICE PERMIT An insurance premium finance branch office license shall be required for each location (other than the home office) at which any books, records or files of the licensee are kept. No branch office license shall be required if all records are t…

11 NCAC 13 .0312 SALE, ASSIGNMENT OR TRANSFER OF PREMIUM FINANCE AGREEMENTS A licensee shall not sell or transfer any ownership of any insurance premium finance agreement or power of attorney to cancel an insurance contract unless the terms and conditions of sale or transfer have…

11 NCAC 13 .0313 ADDITIONAL BALANCES ADDED TO FINANCE AGREEMENTS Any additional balances may be added to a premium finance agreement unless the original or subsequent agreement specifically does not authorize such additions. History Note: Authority G.S. 58-2-40; 58-35-50(a); Eff.…

11 NCAC 13 .0314 ADDITIONAL BALANCES ADDED TO FINANCE AGREEMENTS: 60 DAYS All additional premiums on insurance contracts or all additional insurance contracts added to a premium finance agreement less than 60 days after the date of the premium finance agreement shall be added as …

11 NCAC 13 .0315 ADDITIONAL BALANCES ADDED TO AGREEMENT AFTER 60 DAYS Any additional premiums on insurance contracts or additional insurance contracts added to a premium finance agreement 60 days or more after the date of the agreement (but prior to the expiration of the agreemen…

11 NCAC 13 .0316 ADDITIONAL BALANCE NOTICE TO INSURED When a premium finance agreement provides for the financing of additional balances and such additional balances are added to the agreement by the licensee, a notice of the additional balance shall be mailed to the insured, at …

11 NCAC 13 .0317 TEN-DAY NOTICE The ten-day written notice of intent to cancel as described in G.S. 58-35-85(1) shall include the name and address of the premium finance company, the premium finance agreement number, the date the notice is delivered or sent, and the amount of the…

11 NCAC 13 .0318 NOTICE OF CANCELLATION The notice of cancellation as described in G.S. 58-35-85(2) shall be signed by the owner or an officer of the premium finance company (the owner or officer's facsimile signature may be used), shall have in bold print at its top the wording …

11 NCAC 13 .0319 EFFECTIVE DATE OF CANCELLATION When an insurance premium finance company cancels an insurance policy by using a power of attorney signed by the insured, the effective date of cancellation as stated in the notice of cancellation shall be no earlier than the date t…

11 NCAC 13 .0320 INSTALLMENT PAYMENTS MADE BY INSURED If an insurance premium finance company allows or authorizes an insurance agent, broker or any other representative to accept installment payments from the insured or if the premium finance company accepts installment payments…

11 NCAC 13 .0321 SIGHT DRAFT AND CHECK FORMS The Department will not approve the use of sight draft or any check forms that are placed in the hands of the insurance agents unless they are made payable only to a licensed or authorized insurance company. Such sight draft or check f…

11 NCAC 13 .0322 INSURANCE COMPANY NOTIFIED OF FINANCED POLICY The licensee shall give notice to the insurance company affected when an unearned premium has been assigned by the insured. The premium finance company may give the notice directly to the insurance company or instruct…

11 NCAC 13 .0323 COMPUTATION OF SERVICE CHARGES The service charges as provided in G.S. 58-35-55(c) shall be computed: (1) from the inception date of the insurance contract, the premiums for which are advanced or to be advanced under the agreement, to and including the date when …