Authorization For Health Care Services Not To Be Withdrawn After the Services Have Been Provided, Exceptions

PURPOSES: This rule interprets sections 376.1350(4), 376.1359, 376.1361.12 and 376.1361.13, RSMo Supp. 1997. (1) Utilization review by health carriers for plans containing a managed care component is performed only for covered services, section 376.1359, RSMo Supp. 1997. Therefore, a benefits determination must be performed prior to utilization review under sections 376.1350(4), 376.1361.12 and 376.1361.13, RSMo Supp. 1997. Because a benefits determination must be made prior to utilization review, certification will be deemed to be an authorization of a covered benefit. If an authorized representative of a health carrier authorizes the provision of a health care service, the health carrier shall not subsequently retract its authorization after the health care service has been provided, or reduce payment for an item or service furnished in reliance on approval, unless— (A) Such authorization is based on a material misrepresentation or omission about the treated person’s health condition or the cause of the health condition; or (B) The health benefit plan terminates before the health care services are provided; or (C) The covered person’s coverage under the health benefit plan terminates before the health care services are provided. (2) Where a health carrier has authorized the provision of a health care service and a dispute arises between the health carrier and the provider after the service is rendered concerning whether the provider provided the service in a manner or type authorized by the health carrier, the health carrier must hold the enrollee harmless from claims made against the enrollee by the provider concerning the service, except for applicable copayments, coinsurance and deductibles. Failure to hold the enrollee harmless will be deemed a violation of section 376.1361.13, RSMo as an indirect retraction of the authorization. Notwithstanding any provision of this rule, sections 376.1350–376.1390, RSMo Supp. 1997, do not determine or allocate the responsibility for utilization review decisions as between the health carrier and providers. AUTHORITY: section 374.045.1, RSMo Supp. 1997.* Original rule filed Jan. 6, 1998, effective July 30, 1998. *Original authority: 374.045, RSMo 1967, amended 1993, 1995.