North Carolina Administrative Code

11 NCAC 20 .0404 APPLICATION For all providers who submit applications to be added to a carrier's network: (1) The definitions in G.S. 58-3-167 are incorporated into this Rule by reference. Each carrier that is an insurer that issues a health benefit plan shall obtain and retain …

11 NCAC 20 .0405 VERIFICATION OF CREDENTIALS (a) Each carrier's process for verifying credentials shall take into account and make allowance for the time required to request and obtain primary source verifications and other information that must be obtained from third parties in …

11 NCAC 20 .0406 PROVIDER FILES Each carrier shall maintain centralized files, either paper or electronic, on each individual provider making application to affiliate with the carrier. Each file shall include documentation of compliance with Rules .0404 and .0405 of this Section.…

11 NCAC 20 .0407 REVERIFICATION OF PROVIDER CREDENTIALS Each carrier shall reverify the credentials of all network providers at least every three years. On or after October 1, 2001, carriers shall use the form approved by the Commissioner under G.S. 58-3-230. Carriers may require…

11 NCAC 20 .0408 CONFIDENTIALITY Each carrier shall develop written policies and procedures to protect the confidentiality of patient health or medical record information and personal information, as provided by law. History Note: Authority G.S. 58-2-40(1); 58-2-131; 58-39-45; 58…

11 NCAC 20 .0409 RECORDS AND EXAMINATIONS History Note: Authority G.S. 58-2-40(1); 58-2-131; 58-50-55(b); 58-65-1; 58-65-25; 58-65-105; 58-65-140; 58-67-5; 58-67-10; 58-67-20; 58-67-35; 58-67-65; 58-67-100; 58-67-140; 58-67-150; Eff. October 1, 1996; Amended Eff. January 1, 2009;…

11 NCAC 20 .0410 DELEGATION OF CREDENTIAL VERIFICATION ACTIVITIES Whenever any carrier delegates credential verification activities to a contracting entity, whether an intermediary or subcontractor, the carrier shall review the contracting entity's credential verification program…

11 NCAC 20 .0411 SUSPENSION OR TERMINATION OF NETWORK PROVIDERS Each carrier shall have a mechanism in place to reduce, suspend, or terminate the participation of any network provider. History Note: Authority G.S. 58-2-40(1); 58-50-55(b); 58-65-1; 58-65-25; 58-65-105; 58-65-140; …

SECTION .0500 - HMO QUALITY MANAGEMENT PROGRAMS 11 NCAC 20 .0501 PROGRAM (a) Each HMO shall have a program designed to monitor, evaluate, improve, and promote: (1) The quality of health care and quality of services provided through its network of providers; and (2) Its policies, …

11 NCAC 20 .0502 STRUCTURE Each HMO shall develop and maintain an organizational structure to conduct quality management. The structure shall provide for an identifiable person or persons to be responsible for all quality management, which person or persons shall be capable of ca…

11 NCAC 20 .0503 PLAN Each HMO shall develop and adopt a written quality management plan that contains policies and procedures to support the quality management program. This plan shall include the following: (1) The purpose, goals, and objectives of the quality management progra…

11 NCAC 20 .0504 ACTIVITIES (a) Each HMO shall develop quality of care and quality of service standards and establish a mechanism to determine if the standards are being met. (b) Each HMO shall employ a variety of quality management tools that assess and monitor: (1) The quality …

11 NCAC 20 .0505 QUALITY OF CARE COMPLAINTS Each HMO shall maintain policies and procedures to record, investigate, and take corrective action in response to patient complaints about the quality of care delivered by network providers and decisions made by the HMO. The policies an…

11 NCAC 20 .0506 DELEGATION OF ACTIVITIES Whenever any HMO delegates quality management activities to another entity, the HMO shall review and approve the entity's quality management program before contracting with the entity and shall monitor the entity's quality management acti…

11 NCAC 20 .0507 CORRECTIVE ACTION Each HMO shall have procedures for identifying and taking corrective action on quality of care and quality of service problems related to network providers or the carrier, whether a specific individual or system-wide. History Note: Authority G.S…

11 NCAC 20 .0508 CONFLICTS OF INTEREST Each HMO shall develop written policies and procedures about conflicts of interest. No person shall conduct utilization review of health care provided by any facility or entity in which that person or any member of his or her family has, dir…

11 NCAC 20 .0509 CONFIDENTIALITY Each HMO shall develop written policies and procedures to protect the confidentiality of medical record information and personal information relating to covered individuals, as those terms are defined in G.S. 58-39-15. History Note: Authority G.S.…

11 NCAC 20 .0510 RECORDS AND EXAMINATIONS History Note: Authority G.S. 58-2-40(1); 58-67-5; 58-67-10; 58-67-20; 58-67-35; 58-67-65; 58-67-100; 58-67-140; 58-67-150; Eff. October 1, 1996; Amended Eff. January 1, 2009; Pursuant to G.S. 150B-21.3A, rule Expired January 1, 2015.

11 NCAC 20 .0511 INTERNAL AUDIT Each HMO shall at least annually evaluate its quality management program to assure that it complies with this Section and the HMO's internal standards, policies, and procedures. The effectiveness and efficiency of the program shall also be evaluate…

SECTION .0600 - SIGNIFICANT MODIFICATIONS TO HMO OPERATIONS 11 NCAC 20 .0601 APPLICATIONS FOR MODIFICATIONS TO SERVICE AREAS OR PRODUCT LINES (a) All requests to expand an HMO's service area shall be submitted in electronic format as an application to the Division for review and …

11 NCAC 20 .0602 WRITTEN NOTICE In addition to those modifications set out in G.S. 58-67-10(d)(1), an HMO shall submit written notice to the Division of the following: (1) Changes to the members of the HMO's Board of Directors, Trustees, Officers, or any entity maintaining at lea…

CHAPTER 21 - THIRD PARTY ADMINISTRATORS SECTION .0100 - GENERAL PROVISIONS 11 NCAC 21 .0101 DEFINITIONS: LICENSE APPLICATIONS (a) The definitions in G.S. 58-56-2 are incorporated into this Chapter by reference. (b) In addition to those items listed in G.S. 58-56-51, the following…

11 NCAC 21 .0102 FINANCIAL STATEMENTS The financial statements required by G.S. 58-56-51(b)(4) shall include a balance sheet, a statement of operations, and a statement of cash flows for the TPA's two most recent fiscal years. Financial statements shall be prepared by an independ…

11 NCAC 21 .0103 DETERMINATION OF FINANCIAL RESPONSIBILITY In determining the financial responsibility of an applicant for a TPA license, the Department shall require that an applicant be solvent. In addition, the Department shall consider: (1) Liquidity; (2) Any internal control…

11 NCAC 21 .0104 SERVICE CONTRACTS No TPA shall enter into an agreement to administer insurance with an insurance company or health maintenance organization unless the company or HMO is licensed to operate in North Carolina. History Note: Authority G.S. 58-2-40; 58-56-6; 58-56-51…

11 NCAC 21 .0105 CLAIM ADJUSTING BY TPAs A TPA or an employee of a TPA does not have to have a license to adjust insurance claims for an insurer with which the TPA has a written agreement under G.S. 58-56-6. History Note: Authority G.S. 58-2-40; 58-56-2(5); 58-56-51; Eff. June 1,…

11 NCAC 21 .0106 PAYMENT OF CLAIMS If claims filed with a TPA or insurer are not paid within 30 days after receipt of the initial claim by the TPA or the insurer, the TPA or the insurer shall at that time mail a claim status report to the claimant. History Note: Authority G.S. 58…

11 NCAC 21 .0107 GENERAL ADMINISTRATION Every TPA shall: (1) Establish a governing body that is authorized to set policy for the organization. (2) Maintain complete corporate records in a secure and accessible location. (3) Employ a management information system that is able to p…

11 NCAC 21 .0108 CLAIMS ADMINISTRATION (a) Each TPA's claims administration service shall be supported by a set of written policies, procedures, and performance standards related to timeliness in payment of claims and its financial operations. (b) Each TPA shall develop and imple…

11 NCAC 21 .0109 MARKETING AND SALES (a) Each TPA shall ensure that all direct sales staff and brokers are licensed by the State of North Carolina to sell insurance and meet all continuing education requirements. (b) Each TPA that markets or sells insurance products shall quote o…

11 NCAC 21 .0110 SERVICES TO INSUREDS (a) Each TPA shall make available to insureds and insurers a written description of its premium collection and claims payment policies and procedures. (b) Each TPA shall be accessible to insureds and insurers by telephone to respond to inquir…

Chapter 23 - Industrial Commission SUBCHAPTER 23A - WORKERS' COMPENSATION RULES SECTION .0100 - ADMINISTRATION 11 NCAC 23A .0101 Location of MAIN OFFICE and Hours of Business The main office of the North Carolina Industrial Commission is located in the Dobbs Building, 430 North S…

11 NCAC 23A .0102 OFFICIAL FORMS (a) Copies of the Commission's rules and forms may be obtained by: (1) contacting the Commission in person at the address in Rule .0101 of this Section, by written request mailed to North Carolina Industrial Commission, 1236 Mail Service Center, R…

11 NCAC 23A .0103 Notice of Accident and Claim of Injury or Occupational Disease To give notice of an accident or occupational disease and to make a workers' compensation claim, an employee may complete a Form 18 Notice of Accident to Employer and Claim of Employee, Representativ…

11 NCAC 23A .0104 Employer's Requirement to File FIRST REPORT OF INJURY (a) The form required to be provided by G.S. 97-92(a) is the Form 19 Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission. The Form 19 shall be used when the injury caus…

11 NCAC 23A .0105 ELECTRONIC PAYMENT OF COSTS History Note: Authority G.S. 97-80(a); Eff. January 1, 2011; Rule Expired July 18, 2013 (see S.L. 2013-294, s. 1); Recodified from 04 NCAC 10A .0105 Eff. June 1, 2018.

11 NCAC 23A .0106 Filing of Annual Report Requirement Every carrier, individual self-insurer, group self-insurer, and member self-insurer as defined by G.S. 97-130 shall submit on a yearly basis a Form 51 Annual Consolidated Fiscal Report of "Medical Only" and "Lost Time" Cases. …

11 NCAC 23A .0107 Computation of Time AND NOTICE BY THE COMMISSION (a) Except as otherwise provided by statute or rule, in computing any period of time prescribed or allowed by the Commission Rules, order of the Commission, or any applicable statute, the day of the act, event, or…

11 NCAC 23A .0108 ELECTRONIC FILINGS WITH THE COMMISSION; HOW TO FILE (a) All documents filed with the Commission in workers' compensation cases shall be submitted electronically in accordance with this Rule. Any document transmitted to the Commission in a manner not in accordanc…

11 NCAC 23A .0109 Contact information (a) "Contact information" for purposes of this Rule shall include telephone number, facsimile number, email address, and mailing address. (b) All attorneys of record with matters before the Commission shall provide and maintain current contac…

section .0200 – notice of act 11 NCAC 23A .0201 Posting Requirement for Employers (a) The form required to be posted by G.S. 97-93(e) is the Form 17 Workers' Compensation Notice to Injured Workers and Employers, that includes the following: (1) name of insurer; (2) policy number;…

section .0300 - insurance 11 NCAC 23A .0301 Proof of Insurance Coverage (a) Every employer, either personally or through its carrier or third party administrator, subject to the provisions of the Workers' Compensation Act shall file with the Commission proof that it has obtained …

11 NCAC 23A .0302 Required Contact Information from Carriers All insurance carriers, third party administrators, and self-insured employers shall designate a primary contact person for workers' compensation issues in North Carolina and shall maintain and provide annually on July …

section .0400 – disability, compensation, fees 11 NCAC 23A .0401 CALCULATING THE SEVEN-DAY WAITING PERIOD (a) When the injured employee is not paid wages for the entire day on which the injury occurred, the seven-day waiting period prescribed by the Workers' Compensation Act shal…

11 NCAC 23A .0402 Submission of Earnings Statement Required (a) Within 30 days of a request by the employee or the Commission, the employer shall submit a verified statement of the specific days worked and the earnings of the employee during the 52-week period immediately precedi…

11 NCAC 23A .0403 Manner of Payment of Compensation (a) All payments of compensation shall be made directly to the employee, dependent, guardian or personal representative. Payment of compensation shall be mailed by first class mail, postage pre-paid, to an address specified by t…

11 NCAC 23A .0404 Termination and Suspension of Compensation (a) No application to terminate or suspend compensation shall be approved by the Commission without a formal hearing if the effect of the approval is to set aside the provisions of an award of the Commission. (b) When a…

11 NCAC 23A .0405 REINSTATEMENT OF COMPENSATION (a) In a claim in which the employer, carrier, or administrator has admitted liability, when an employee seeks reinstatement of compensation pursuant to G.S. 97-18(k), the employee may notify the employer, carrier, or administrator …

11 NCAC 23A .0406 Discount Rate to Be Used in Determining Commuted Values To compute the present value of unaccrued compensation payments, the parties shall utilize the Internal Revenue Service's Applicable Federal Rate or the discount rate that is: (1) used to determine the pres…

11 NCAC 23A .0407 Fees for Medical Compensation History Note: Authority G.S. 97-18(i); 97-25.6; 97-26; 97-80(a); 138-6; Eff. January 1, 1990; Amended Eff. June 1, 2000; March 15, 1995; Repealed Eff. November 1, 2014; Recodified from 04 NCAC 10A .0407 Eff. June 1, 2018.