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The Vermont Statutes Online

 

Title 18 : Health

Chapter 221 : HEALTH CARE ADMINISTRATION

Subchapter 002 : Claims Processing and Contract Standards

(Cite as: 18 V.S.A. § 9418c)
  • § 9418c. Fair contract standards

    (a) Required information.

    (1) Each contracting entity shall provide and each health care contract shall obligate the contracting entity to provide participating health care providers information sufficient for the participating provider to determine the compensation or payment terms for health care services, including all of the following:

    (A) The manner of payment, such as fee-for-service, capitation, case rate, or risk.

    (B) On request, the fee-for-service dollar amount allowable for each CPT code for those CPT codes that a provider in the same specialty typically uses or that the requesting provider actually bills. Fee schedule information may be provided by CD-ROM or electronically, at the election of the contracting entity, but a provider may elect to receive a hard copy of the fee schedule information instead of the CD-ROM or electronic version.

    (C) A clearly understandable, readily available mechanism, such as a specific website address, that includes the following information:

    (i) the name of the commercially available claims editing software product that the health plan, contracting entity, covered entity, or payer uses;

    (ii) the standard or standards from subsection 9418a(c) of this title that the entity uses for claim edits;

    (iii) payment percentages for modifiers; and

    (iv) any significant edits, as determined by the health plan, contracting entity, covered entity, or payer, added to the claims software product, which are made at the request of the health plan, contracting entity, covered entity, or payer, and which have been approved by the Commissioner pursuant to subsection 9418a(b) or (c) of this title.

    (2) Contracting entities shall provide the information described in subdivisions (1)(A) and (B) of this subsection to health care providers who are actively engaged in the process of determining whether to become a participating provider in the contracting entity's network.

    (3) Contracting entities may require health care providers to execute written confidentiality agreements with respect to fee schedule and claim edit information received from contracting entities.

    (4) Each health care contract shall include the following information:

    (A) Any product, company, or network for which the participating provider has agreed to provide services.

    (B) For each product or network, reimbursement terms and methodologies, unless the terms are identical for multiple products or networks.

    (C) The term of the health care contract.

    (D) Termination notice period and reasons for termination.

    (E) Language that identifies the entity responsible for the processing of the participating provider's compensation or payment, including contact information, including telephone, fax, and e-mail. This requirement may be satisfied by providing a specific web address that contains the necessary information.

    (F) Any internal mechanism provided by the contracting entity to resolve disputes concerning the interpretation or application of the terms and conditions of the contract. A contracting entity may satisfy this requirement by providing a clearly understandable, readily available mechanism, such as a specific website address or an appendix, that allows a participating provider to determine the procedures for the internal mechanism to resolve those disputes.

    (G) A list of addenda, if any, to the contract.

    (b) Summary disclosure form.

    (1) Each contracting entity shall include a summary disclosure form with a health care contract that includes all of the information specified in subsection (a) of this section. The information in the summary disclosure form shall refer to the location in the health care contract, whether a page number, section of the contract, appendix, or other identifier, that specifies the provisions in the contract to which the information in the form refers.

    (2) The summary disclosure form shall include all of the following information:

    (A) That the form is merely a guide to the health care contract and that the terms and conditions of the health care contract constitute the actual contract rights of the parties.

    (B) That reading the form is not a substitute for reading the entire health care contract.

    (C) That by signing the health care contract, the participating provider will be bound by the contract's terms and conditions.

    (D) That the terms and conditions of the health care contract may be amended pursuant to section 9418d of this title, and the participating provider is encouraged to carefully read any proposed amendments sent after execution of the contract.

    (E) That nothing in the summary disclosure form creates any additional rights or causes of action in favor of either party.

    (3) No contracting entity that includes any information in the summary disclosure form with the reasonable belief that the information is truthful and accurate shall be subject to a civil action for damages or to binding arbitration based on information included in the summary disclosure form. Inclusion of intentional misstatements or intentional misrepresentations in the summary disclosure form shall be considered a violation of this chapter subject to enforcement under section 9418g of this title. This section does not impair or affect any power of the Department of Financial Regulation to enforce any applicable law.

    (4) The summary disclosure form described in subdivisions (1) and (2) of this subsection shall be in substantially the following form:

    "SUMMARY DISCLOSURE FORM

        Compensation terms

    Manner of payment:

       [   ] Fee for service

                   [   ] Capitation

       [   ] Risk

       [   ] Other  ............... See  ...............

    Reimbursement schedule available at  ....................

    Claim edit information available at  ....................

    List of products, product types, or networks covered by this contract (fill in  names as applicable):

       [   ]  ...............

       [   ]  ...............

       [   ]  ...............

       [   ]  ...............

       [   ]  ...............

    Term of this contract  ............................................................................

    Termination notice period  ....................................................................

    Contracting entity, covered entity, or payer responsible for processing payment available at  .........................................................................................

    Internal mechanism for resolving disputes regarding contract terms available at  ........................................................................................................

    Addenda to contract (list addenda, if any)

    Telephone number to access a readily available mechanism, such as a specific website address, to allow a participating provider to receive the information listed above from the payer:  ...........................................................

    Rental network information

    ...................................................................................................................

    ...................................................................................................................

    IMPORTANT INFORMATION – PLEASE READ CAREFULLY

    The information provided in this Summary Disclosure Form is a guide to the attached Health Care Contract. The terms and conditions of the attached Health  Care Contract constitute the contract rights of the parties.

    Reading this Summary Disclosure Form is not a substitute for reading the entire Health Care Contract. When you sign the Health Care Contract, you will be bound by its terms and conditions. These terms and conditions may be amended over time pursuant to 18 V.S.A. § 9418d. You are encouraged to read any proposed amendments that are sent to you after execution of the Health Care Contract.

    Nothing in this Summary Disclosure Form creates any additional rights or causes of action in favor of either party."

    (5) Upon request, contracting entities shall provide the summary disclosure form to a participating provider or a provider who is actively engaged in the process of determining whether to become a participating provider within 60 days of the request.

    (c) When a contracting entity presents a proposed health care contract for consideration by a provider, the contracting entity shall provide in writing or make reasonably available the information required in subdivisions (a)(1)(A) and (B) of this section.

    (d) Upon request, the contracting entity shall identify any utilization management, quality improvement, price or quality transparency program, or a similar program that the contracting entity uses to review, monitor, evaluate, or assess the services provided pursuant to a health care contract. The contracting entity shall disclose the policies, procedures, or guidelines of such a program upon request by the participating provider who is subject to or is participating in the program within 14 days after the date of the request.

    (e) The requirements of subdivision (b)(5) of this section do not prohibit a contracting entity from requiring a reasonable confidentiality agreement between the provider and the contracting entity regarding the terms of the proposed health care contract. (Added 2009, No. 61, § 32.)