The Vermont Statutes Online

Title 18 : Health

Chapter 221 : Health Care Administration

Subchapter 002 : Claims Processing and Contract Standards

• § 9418f. Rental network contracts

  (a) Definitions. As used in this section:

  (1) “Health care services” means services for the diagnosis, prevention, treatment, or cure of a health condition, illness, injury, or disease.

  (2)(A) “Provider” means a physician, a physician organization, or a physician hospital organization that is acting exclusively as an administrator on behalf of a provider to facilitate the provider’s participation in health care contracts.

  (B) “Provider” does not include a physician organization or physician hospital organization that leases or rents the physician organization’s or physician hospital organization’s network to a covered entity.

  (3) “Provider network contract” means a contract between a contracting entity and a provider specifying the rights and responsibilities of the contracting entity and provider for the delivery of and payment for health care services to covered individuals.

  (b) Scope. This section shall not apply to:

  (1) Provider network contracts for services provided to Medicaid, Medicare, or the State Children’s Health Insurance Program (SCHIP) beneficiaries.

  (2) Circumstances in which access to the provider network contract is granted to an entity operating under the same brand licensee program as the contracting entity.

  (c) Registration.

  (1) Any person not otherwise licensed or registered by the Commissioner that intends to conduct business as a contracting entity shall register with the Commissioner prior to commencing business. Each person not licensed or registered by the Commissioner as a contracting entity upon the effective date of this section shall have 30 days within which to register with the Commissioner.

  (2) Registration shall consist of the submission of the following information:

  (A) the official name of the contracting entity;

  (B) the mailing address and main telephone number for the contracting entity’s main headquarters; and

  (C) the name and telephone number of the contracting entity’s representative who shall serve as the primary contact with the Commissioner.

  (3) The information required by this subsection shall be submitted in written or electronic format, as prescribed by the Commissioner.

  (4) Annually on July 1, each person registered as a contracting entity under this section shall pay to the Commissioner a fee of $200.00. Fees collected under this subdivision shall be deposited into the Health Care Special Fund, number 21070, and shall be available to the Commissioner to offset the cost of administering the registration process.

  (d) Contracting entity rights and responsibilities.

  (1) A contracting entity may not grant access to a provider’s health care services and contractual discounts pursuant to a provider network contract unless:

  (A) the provider network contract specifically states that the contracting entity may enter into an agreement with a third party, allowing the third party to obtain the contracting entity’s rights and responsibilities under the provider network contract as if the third party were the contracting entity; and

  (B) the third party accessing the provider network contract is contractually obligated to comply with all applicable terms, limitations, and conditions of the provider network contract.

  (2) A contracting entity that grants access to a provider’s health care services and contractual discounts pursuant to a provider network contract shall:

  (A) identify and provide to the provider, upon request at the time a provider network contract is entered into with a provider, a written or electronic list of all third parties known at the time of contracting, to which the contracting entity has or will grant access to the provider’s health care services and contractual discounts pursuant to a provider network contract;

  (B) maintain a website or other readily available mechanism, such as a toll-free telephone number, through which a provider may obtain a listing, updated at least every 90 days, of the third parties to which the contracting entity has executed contracts to grant access to such provider’s health care services and contractual discounts pursuant to a provider network contract;

  (C) provide the covered entity with sufficient information regarding the provider network contract to enable the covered entity to comply with all relevant terms, limitations, and conditions of the provider network contract;

  (D) require that the covered entity who contracts with the contracting entity to gain access to the provider network contract identify the source of the contractual discount taken by the covered entity on each remittance advice or explanation of payment form furnished to a health care provider when such discount is pursuant to the contracting entity’s provider network contract;

  (E) notify the covered entity who contracts with the contracting entity to gain access to the provider network contract of the termination of the provider network contract not later than 30 days prior to the effective date of the final termination of the provider network contract; and

  (F) require those that are by contract eligible to claim the right to access a provider’s discounted rate to cease claiming entitlement to those rates or other contracted rights or obligations for services rendered after termination of the provider network contract.

  (3) The notice required under subdivision (2)(E) of this subsection can be provided through any reasonable means, including written notice, electronic communication, or an update to an electronic database or other provider listing.

  (4) Subject to any applicable continuity of care requirements, agreements, or contractual provisions:

  (A) a covered entity’s right to access a provider’s health care services and contractual discounts pursuant to a provider network contract shall terminate on the date the provider network contract is terminated;

  (B) claims for health care services performed after the termination date of the provider network contract are not eligible for processing and payment in accordance with the provider network contract; and

  (C) claims for health care services performed before the termination date of the provider network contract, but processed after the termination date, are eligible for processing and payment in accordance with the provider network contract.

  (5)(A) All information made available to providers in accordance with the requirements of this section shall be confidential and shall not be disclosed to any person or entity not involved in the provider’s practice or the administration thereof without the prior written consent of the contracting entity.

  (B) Nothing in this section shall be construed to prohibit a contracting entity from requiring the provider to execute a reasonable confidentiality agreement to ensure that confidential or proprietary information disclosed by the contracting entity is not used for any purpose other than the provider’s direct practice management or billing activities.

  (e) Rental by third parties prohibited. A covered entity, having itself been granted access to a provider’s health care services and contractual discounts pursuant to a provider network contract, may not further lease, rent, or otherwise grant access to the contract to any other person.

  (f) Unauthorized access to provider network contracts.

  (1) It is a violation of this subchapter subject to enforcement under section 9418g of this title to access or utilize a provider’s contractual discount pursuant to a provider network contract without a contractual relationship with the provider, contracting entity, or covered entity, as specified in this section.

  (2) Contracting entities and third parties are obligated to comply with subdivision (d)(2)(B) of this section concerning the services referenced on a remittance advice or explanation of payment. A provider may refuse the discount taken on the remittance advice or explanation of payment if the discount is taken without a contractual basis or in violation of these sections. However, an error in the remittance advice or explanation of payment may be corrected within 30 days following notice by the provider.

  (3) A contracting entity may not lease, rent, or otherwise grant a covered entity access to a provider network contract unless the covered entity accessing the health care contract is:

  (A) a payer, a third party administrator, or another entity that administers or processes claims on behalf of the payer;

  (B) a preferred provider organization or preferred provider network, including a physician organization or physician hospital organization; or

  (C) an entity engaged in the electronic claims transport between the contracting entity and the payer that does not provide access to the provider’s services and a discount to any other covered entity. (Added 2009, No. 61, § 35; amended 2023, No. 6, § 235, eff. July 1, 2023.)