Intermediaries

Intermediaries A contract between a health carrier and an intermediary shall satisfy all the requirements contained in this section. A. Intermediaries and participating providers with whom they contract shall comply with all the applicable requirements of Rule 14.06. B. A health carrier’s statutory responsibility to monitor the offering of covered benefits to covered persons shall not be delegated or assigned to the intermediary. C. A health carrier shall have the right to approve or disapprove participation status of a subcontracted provider in its own or a contracted network for the purpose of delivering covered benefits to the carrier’s covered persons. D. A health carrier shall maintain copies of all intermediary health care subcontracts at its principal place of business in the state or ensure that it has access to all intermediary subcontracts. A health carrier shall make copies of intermediary contracts available to the Commissioner upon demand. E. If applicable, an intermediary shall transmit utilization documentation and claims paid documentation to the health carrier. The carrier shall monitor the timeliness and appropriateness of payments made to providers and health care services received by covered persons. F. If applicable, an intermediary shall maintain the books, records, financial information and documentation of services provided to covered persons at its principal place of business in the state and preserve them in a manner that facilitates regulatory review by the Commissioner. G. An intermediary shall allow the Commissioner access to the intermediary’s books, records, financial information, and any documentation of services provided to covered persons, as necessary to determine compliance with this Regulation. H. A health carrier shall have the right, in the event of the intermediary’s insolvency, to require the assignment to the health carrier of the provisions of a provider’s contract addressing the provider’s obligation to furnish covered services.