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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9231/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9231 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9231 - Title
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This chapter shall be known and may be cited as the Chapter on Health Information Protection.
History —Aug. 29, 2011, No. 194, added as § 14.010 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9232/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9232 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9232 - Purpose
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The purpose of this chapter is to establish standards for the protection of the health information of covered persons or enrollees requiring health insurance organizations and issuers to establish procedures for the proper management of any health information generated, maintained, used or disclosed as part of their operations. Any provision of this chapter that is in conflict with the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996, as amended, or any applicable federal law, shall be deemed amended to be consistent with the applicable federal law and rule.
History —Aug. 29, 2011, No. 194, added as § 14.020 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9233/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9233 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9233 - Definitions
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For purposes of this chapter:
(a) Disclose.— Means to release, transfer, or otherwise divulge protected health information.
(b) Health information.— Means any information or data, whether oral or recorded, in any form or medium that:
(1) Is created or received by the health service organization or issuer.
(2) Is related to the past, present or future physical, mental or behavioral health or condition of an individual or a member of the individual's family; the provision of healthcare services to an individual or the past, present or future payment for the provision of healthcare services to an individual.
(3) Is related to the payment for the provision of healthcare services to an individual.
(4) Includes, for purposes of this Health Insurance Code, demographic, genetic, financial exploitation, or abuse information, as such term is defined in §§ 10371–10377 this title.
(c) Protected health information.— Means health information:
(1) That identifies an individual who is the subject of the information, or
(2) with respect to which there is a reasonable basis to believe that the information could be used to identify an individual.
Identifiers shall include, but not be limited to:
(A) Name or nickname of the individual, his/her family members or employers.
(B) Address, except that the information is provided in the aggregate by municipality.
(C) Any element of dates (except year) directly related to a particular person, including date of birth, admission or discharge date or date of death.
(D) Telephone number, fax number, bank account number, social security number, policy or contract number, email address, medical record number, driver's license number.
(E) Biometric identifiers.
(F) Full face photography, among others.
(d) Research.— Means the process of inquiry including, but not limited to, any of the following: the systematic development and testing of a hypothesis; and the description and analysis of processes, behaviors and physical, social, political or medical phenomena.
(e) Scientific, medical or public policy research.— Means research conducted to improve the effectiveness of diagnosis and treatment procedures or the operations of the public or private healthcare systems, the results or findings of which are intended for publication or dissemination to benefit the public in general. Provided, That the scientific, medical or public policy research excludes all activities listed in § 9240(h)(1) of this title.
(f) Unauthorized.— Means a collection, use or disclosure of protected health information made by a health insurance organization or issuer without the authorization of the subject of that protected health information or that is not in compliance with this chapter.
(g) Insurance support organization.— Means a person or entity that regularly engages in the practice of collecting information from health insurance organizations or issuers, producers or other insurance support organizations for the purpose of ratemaking or ratemaking-related functions, detecting or preventing fraud or material misrepresentation in connection with insurance underwriting or insurance claim activity. For purposes of this chapter, insurance producers, government institutions, healthcare institutions and healthcare professionals shall not be considered “insurance support organizations”.
(h) Research organization.— Means a person or organization engaged in scientific, medical or public policy research and that has an Institutional Review Board.
History —Aug. 29, 2011, No. 194, added as § 14.030 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9234/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9234 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9234 - Applicability and scope
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This chapter applies to all health insurance organizations or issuers and governs the management of health information, including the collection, use, and disclosure of protected health information by health insurance organizations or issuers.
History —Aug. 29, 2011, No. 194, added as § 14.040 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9235/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9235 - Health information policies, standards and procedures
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9235 - Health information policies, standards and procedures
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(a) A health insurance organization or issuer shall develop and implement written policies, standards, and procedures for the management of health information, in order to guard against the unauthorized collection, use, or disclosure of protected health information. It shall meet the applicable requirements of the Federal Privacy and Security Rules issued in accordance to HIPAA. Such policies, standards, and procedures shall include:
(1) Limitation on access to health information based on the functions of its employees;
(2) appropriate training for all employees;
(3) disciplinary measures for violations of the health information policies, standards, and procedures;
(4) identification of the job titles and job descriptions of persons that are authorized to disclose protected health information;
(5) procedures for authorizing and restricting the collection, use, or disclosure of protected health information;
(6) methods for exercising the right to access and amend protected health information, as provided in §§ 9237 and 9238 of this title;
(7) methods for handling, disclosing, storing, and disposing of health information;
(8) periodic monitoring of the employees' compliance with the health insurance organization or issuer's policies, standards, and procedures, and
(9) methods for informing and allowing an individual who is the subject of protected health information to request specialized disclosure or nondisclosure of protected health information, as required under § 9244 of this title.
(b)
(1) A health insurance organization or issuer shall take the necessary measures to assure that any person or entity with which it contracts to carry out functions related to the collection, disclosure, management, or use of protected health information complies with the following:
(A) Has policies, standards, and procedures that meet the requirements of this chapter regarding health information, and
(B) knows its obligation to meet any applicable Commonwealth and federal statutory and regulatory requirements governing the collection, use or disclosure of protected health information.
(2) In any contractual arrangement between the health insurance organization or issuer and a provider, the health insurance organization or issuer shall require that the healthcare provider have health information privacy policies, standards and procedures.
(c) A health insurance organization or issuer shall make the health information policies, standards and procedures developed pursuant to this section available for review and inspection by the Commissioner.
History —Aug. 29, 2011, No. 194, added as § 14.050 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9236/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9236 - Notice of health information policies, standards, and procedures
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9236 - Notice of health information policies, standards, and procedures
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(a) A health insurance organization or issuer shall draft a written notice of its health information policies, standards, and procedures, which shall be made available for review and inspection by the Commissioner. The notice shall include:
(1) The collection, use, and disclosure of protected health information prohibited and permitted by this chapter;
(2) the procedures for authorizing and limiting disclosures of protected health information and for revoking authorizations;
(3) the procedures for accessing and amending protected health information, and
(4) the right of a covered person or enrollee to review a copy of the health insurance organization or issuer's health information policies, standards and procedures.
(b) The health insurance organization or issuer shall provide the notice to any covered person or enrollee at the time the policy is first delivered, and to any other person upon request.
History —Aug. 29, 2011, No. 194, added as § 14.060 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9237/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9237 - Right to access protected health information
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9237 - Right to access protected health information
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(a) Subject to the exceptions listed in subsection (b)(3) of this section, an individual who is the subject of the protected health information has the right to examine or receive a copy of the protected health information that is in the possession of the health insurance organization or issuer.
(b) An individual who is the subject of protected health information may request access to such information in writing to the health insurance organization or issuer. Not later than thirty (30) working days after receipt of such written request, a health insurance organization or issuer shall do one of the following: If it needs additional time to make the report, the health service organization or issuer shall have an additional term of thirty (30) calendar days to respond to the individual that made the request. Such additional term shall be notified to the individual that made the request prior to the expiration of the initial term, explaining the reasons therefor:
(1) Provide a copy of the protected health information requested to the individual or if providing a copy is not possible, permit the individual to examine the protected health information during regular business hours;
(2) notify the individual that it does not have the protected health information and, if known, inform the individual of the name and address of the person who has the protected health information requested, or
(3) deny the request in whole or in part if the health insurance organization or issuer determines any of the following:
(A) Knowledge of the protected health information would reasonably be expected to identify a confidential source who provided the same in conjunction with a lawfully conducted investigation or court proceeding;
(B) the protected health information was compiled in preparation for litigation, law enforcement or fraud investigation, or quality assurance purposes;
(C) the protected health information is the original work product of the health insurance organization or issuer, which would include but not be limited to interpretation, mental impressions, instructions and other original product of the health insurance organization or issuer, its employees and agents;
(D) the requester is a party to a legal proceeding involving the health insurance organization or issuer where the health condition of the requester is at issue, subject to the provisions of the Rules of Civil or Criminal Procedure or of Evidence in effect related to discovery in tort claims involving medical malpractice. However, once a legal proceeding is resolved, the individual's right to access protected health information shall be restored, or
(E) Disclosure of the protected health information to the individual who is the subject of the protected health information is otherwise prohibited by law.
(c) If a request to examine or copy protected health information is denied in whole or in part, the health insurance organization or issuer shall notify the individual the reasons for the denial in writing. When the protected health information was compiled in preparation for litigation, or as part of an investigation, the health insurance organization or issuer is not required to notify the individual of the reasons for the denial.
(d) A health insurance organizations or issuer is not required to create a new record in order to meet a request for protected health information.
(e) The health insurance organization or issuer may charge a reasonable fee for providing the protected health information requested and shall provide a detailed bill accounting for the charges. No charge shall be made for reproduction of protected health information requested for the purpose of supporting a claim or an appeal, or accessing any federal or Commonwealth sponsored or operated health benefit program.
History —Aug. 29, 2011, No. 194, added as § 14.070 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9238/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9238 - Right to amend protected health information
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9238 - Right to amend protected health information
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(a) An individual who is the subject of protected health information has the right to submit a written request to the health insurance organization or issuer to amend such information to correct any inaccuracies. The individual must present attesting evidence that justifies such amendment.
(b) Not later than sixty (60) calendar days after receipt of a written request to amend protected health information, a health insurance organization or issuer may have an additional thirty (30) calendar-day term to act on such request.
Such additional period of time shall be notified to the individual before the initial term elapses explaining the reasons for the delay. The health insurance organization or issuer shall verify the accuracy of protected health information and do one of the following:
(1) Correct or amend the information in question and notify the individual of the changes, or
(2) notify the individual that the request for amendment has been denied, the reason for the denial, and that the individual may:
(A) Request that the healthcare provider or entity that created the record in question amend the record. The health insurance organization or issuer shall include the healthcare provider's name and address, or
(B) file a concise statement of what the individual believes to be the correct information and the reasons why the individual disagrees with the denial. The health insurance organization or issuer shall retain the statement filed by the individual with the protected health information.
(c) If the health insurance organization or issuer corrects or amends the protected health information as provided in this section, it shall furnish the correction or amendment to:
(1) Any healthcare service provider, contractor, or authorized person who has received the protected health information that has been corrected or amended from the health insurance organization or issuer within the preceding two (2) years;
(2) an insurance support organization whose primary source of protected health information is health insurance organizations or issuers, as long as the insurance support organization has systematically received protected health information from the health insurance organization or issuer within the preceding seven (7) years. However, the correction, amendment or deletion need not be furnished if the insurance support organization no longer maintains the protected health information that has been corrected or amended, and
(3) any person who furnished the protected health information that was amended.
(d) If the individual who is the subject of the protected health information files a statement pursuant to subsection (b)(2)(B) of this section, the health insurance organization or issuer shall:
(1) Clearly identify the matter or matters in dispute and include the statement in any subsequent disclosure of the protected health information, and
(2) Furnish the statement to the persons described in subsection (c) of this section.
History —Aug. 29, 2011, No. 194, added as § 14.080 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9239/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9239 - List of disclosures of protected health information
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9239 - List of disclosures of protected health information
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(a) A health insurance organization or issuer shall provide, upon request, to an individual who is the subject of the protected health information, information regarding disclosure of that individual's protected health information that is sufficient to exercise the right to amend the information pursuant to § 9238 of this title. This information shall include the date, purpose, recipient, and relevant authorization or basis for the disclosure. The health insurance organization or issuer may charge a reasonable fee for providing the information regarding the disclosures of information.
(b) The list shall not include the following disclosures:
(1) Disclosures related to healthcare payment, treatment, and operations;
(2) disclosures made or authorized by the individual;
(3) disclosures made for purposes of national security or intelligence services, and
(4) disclosures to penal institutions or law enforcement officers.
(c) A health insurance organization or issuer shall maintain a system that allows the Commissioner to determine that the health insurance organization or issuer can actually produce a complete list of disclosures.
(1) For routine disclosures, a health insurance organization or issuer shall be able to track when routine disclosures are made, to whom they are made and for what purpose they are made, and
(2) for all other disclosures, a health insurance organization or issuer shall be able to identify the authorization or release form or provision of law allowing the receipt or disclosure of protected health information.
History —Aug. 29, 2011, No. 194, added as § 14.090 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9240/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9240 - Authorization for collection, use or disclosure of protected health information
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9240 - Authorization for collection, use or disclosure of protected health information
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(a) A health insurance organization or issuer shall not collect, use or disclose protected health information without a valid authorization from the subject of the protected health information, except as permitted by § 9241 of this title or as required by law or court order. An authorization for the disclosure of protected health information may be obtained for any purpose, provided that the authorization meets the requirements of this section.
(b) A health insurance organization or issuer shall retain a copy of the authorization in the record of the individual who is the subject of such information.
(c) A valid authorization shall be in writing and contain all the following:
(1) The identity of the individual who is the subject of the protected health information.
(2) A description of the types of protected health information to be collected, used or disclosed.
(3) The identity of the person or entity authorized to use or disclose protected heath information.
(4) The name and address of the person to whom the protected health information is to be disclosed.
(5) The purpose of the authorization, including the reason for the collection, the intended use, and the scope of any disclosures that may be made.
(6) The signature of the individual who is the subject of the protected health information or the individual who is legally empowered to grant authority and the date signed.
(7) A statement that the individual who is the subject of the protected health information may revoke the authorization at any time, and that such cancellation shall be a prospective one.
(8) A statement advising the individual that the information used or disclosed in accordance with the authorization may be disclosed, in turn, by the recipient thereof and may not be protected under the applicable privacy laws.
(d) An authorization shall specify the length of time for which it shall remain valid, which in no event shall be for more than twenty-four (24) months, except an authorization signed for one of the following purposes:
(1) To support an application for, a reinstatement of, or a change in benefits under a life insurance policy, in which event the authorization shall remain valid for thirty (30) months or until the application is denied, whichever occurs first, or
(2) to support or facilitate ongoing treatment of a chronic condition or illness or rehabilitation from an injury.
(e) A health insurance organization or issuer shall require a separate authorization to disclose protected health information to an individual's employer, including the employer's designated risk manager or producer, unless:
(1) The protected health information is disclosed pursuant to the employer's workers' compensation program, to the extent necessary for the performance of the employer's and health insurance organization or issuer's rights and duties under Commonwealth laws on the matter.
(2) Subscription and eligibility information of the participants and beneficiaries of a group health plan is disclosed to the employer such as the coverage of each person, enrollment in or termination of plan, among others.
(3) Statistical information of the health plan is disclosed to the employer without identifiers.
(4) The health information is necessary for the administration of claims pursuant to a commercial lines policy.
(f) A health insurance organization or issuer shall obtain a separate authorization to collect, use or disclose protected health information if the purpose of the collection, use or disclosure is for the marketing of services or goods, or for other commercial gain. The purpose of the collection, use or disclosure shall appear as a separate paragraph in bold type not smaller than twelve (12) point. The purpose shall be stated in clear and simple terms. The request for authorization shall specify that the authorization shall remain valid for not more than twenty-four (24) months and may be revoked at any time. The request for authorization shall state that the terms and conditions of all insurance policies will not be affected in any way by a refusal to give authorization. Notwithstanding the foregoing, a separate authorization is not required if the use or disclosure is internal or to an affiliate of the health insurance organization or issuer and the only use of the information will be in connection with the marketing of an insurance product, provided the affiliate agrees not to disclose the information for any other purpose or to unaffiliated persons.
(g) An individual who is the subject of protected health information may revoke an authorization for disclosure at any time, subject to the rights of any person who acted in reliance on the authorization prior to notice of revocation. A revocation of an authorization shall be in writing, dated and signed. A revocation of an authorization shall be retained by the health insurance organization or issuer in the record of the individual who is the subject of the protected health information. A health insurance organization or issuer shall give prompt notice of the revocation to all persons to whom the health insurance organization or issuer has disclosed protected health information in reliance on the initial authorization.
(h)
(1) A health insurance organization or issuer that has collected protected health information pursuant to a valid authorization in accordance with this chapter may use and disclose such information to authorized persons.
(2) The protected health information shall not be used or disclosed for any purpose other than in the performance of the health insurance organization or issuer's insurance functions, except as otherwise permitted in this chapter or by federal law.
(i) An authorization to collect, use, or disclose protected health information pursuant to this chapter or a production of protected health information pursuant to a court order shall not be construed to constitute a waiver of any other privacy right that may be provided to an individual who is the subject of protected health information under other federal or Commonwealth laws, case law, or Rules of Evidence.
(j) A person who receives protected health information from a health insurance organization or issuer shall not use the protected health information for any purpose other than the lawful purpose for which it was disclosed.
(k) A health insurance organization or issuer that has collected protected health information prior to the effective date of this chapter is not required to obtain an authorization for the information. However, the information may only be used or disclosed in accordance with this chapter after the effective date.
History —Aug. 29, 2011, No. 194, added as § 14.100 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9241/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9241 - Collection, use, and disclosure of protected health information without authorization
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9241 - Collection, use, and disclosure of protected health information without authorization
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(a) A health insurance organization or issuer may, without authorization, engage in the activities related to the payment of services and treatment, and the coordination thereof, as well as healthcare operations, as these terms are defined under HIPPA, including, but not limited to the following activities with regard to protected health information:
(1) Collect protected health information from or disclose protected health information to a health insurance organization or issuer, or a healthcare provider provided that the health insurance organization or issuer that is receiving the information:
(A) Is investigating, evaluating, adjusting, or settling a claim involving the individual who is the subject of the protected health information, or
(B) has become or is considering becoming liable under a policy insuring the individual who is the subject of the protected health information as a result of a merger, acquisition or other assumption of such liability.
(2) Collect, use, or disclose protected health information to the extent necessary to investigate, evaluate, subrogate, or settle claims, provided that the claimant is the subject of the protected health information and such information is used for no other purpose;
(3)
(A) Collect, use, or disclose protected health information to or from an insurance support organization, provided that:
(i) The insurance support organization has in place health information policies, standards, and procedures to ensure compliance with the requirements of this chapter; and
(ii) the protected health information is used only to settle claims, detect and prevent fraud, or detect and prevent material misrepresentation or material nondisclosure, or
(iii) the protected health information is collected and used internally only for ratemaking and ratemaking-related functions or cost analysis.
(4) If the protected health information is necessary to provide ongoing healthcare treatment, and if the disclosure has not been limited or prohibited by the individual who is the subject of the information, the health insurance organization or issuer may collect from or disclose protected health information to:
(A) A healthcare provider, employed by the health insurance organization or issuer, who is furnishing healthcare to a covered person or enrollee.
(B) A healthcare provider with whom the health insurance organization or issuer contracts to provide healthcare services to covered person or enrollee; or
(5) Disclose protected health information to a person engaged in the assessment, evaluation, or investigation of the quality of healthcare furnished by a provider pursuant to federal or Commonwealth statutory or regulatory standards or pursuant to the requirements of a private or public program authorized to provide payment of healthcare.
(6) Subject to the limits of § 9244(a) of this title, disclose protected health information to reveal a covered person or enrollee’s presence in a facility owned by the health insurance organization or issuer and the covered person or enrollee’s general health condition, provided that the disclosure is limited to “directory information”, unless the covered person or enrollee has restricted that disclosure or the disclosure is otherwise prohibited by law. For purposes of this clause, “directory information” means information about the presence or general health condition of a particular covered person or enrollee who is a patient or is receiving emergency healthcare in a healthcare facility. “General health condition” means the covered person or enrollee’s health condition or status described as “critical”, “poor”, “fair”, “good”, “excellent”, or in terms that denote similar conditions.
(7) Collect, use, or disclose protected health information when such information is necessary to the performance of the health insurance organization or issuer’s obligations under any workers’ compensation law.
(8) Collect protected health information from or disclose protected health information to a reinsurer for the purpose of underwriting reinsurance, adjudicating claims, and conducting claim file audits.
(9) Collect protected health information from the individual who is the subject thereof.
(10) Collect, use, or disclose protected health information when the protected health information is obtained from public sources such as the press, public agency reports, and law enforcement or public safety reports.
(b) A health insurance organization or issuer shall disclose protected health information in any of the following circumstances:
(1) To federal, Commonwealth, or local governmental authorities to the extent disclosing the information is required by law or for fraud reporting purposes;
(2) the protected health information is needed for one of the following purposes:
(A) To identify a deceased individual;
(B) to determine the cause and manner of death by a medical examiner or the medical examiner’s designee, or
(C) to provide necessary protected health information about a deceased individual who is a donor of an anatomical gift;
(3) to an insurance regulating entity that is performing an examination, investigation, or audit of the health insurance organization or issuer, or
(4) pursuant to a court order issued after the court’s determination:
(A) that the public interest in disclosure outweighs the covered person or enrollee’s privacy interest, and
(B) that the protected health information is not reasonably available by other means.
History —Aug. 29, 2011, No. 194, added as § 14.110 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9242/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9242 - Collection, use, or disclosure of protected health information without authorization for sc...
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9242 - Collection, use, or disclosure of protected health information without authorization for scientific, medical and public policy research
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(a) A health insurance organization or issuer may disclose protected health information with authorization from the individual who is the subject of such information to research organizations conducting scientific, medical, or public policy research as provided in this section.
(b)
(1) A health insurance organization or issuer shall keep a record of research organizations to which protected health information is disclosed and shall keep the record five (5) years.
(c) A health insurance organization or issuer shall not disclose protected health information to a research organization until evidence is presented that the covered persons have been notified of the information requested to the health insurance organization or issuer and they have had the opportunity to accept or deny such request. The research organization may disclose the protected health information to its agents, collaborators, or contractors as needed to conduct or assist with the research, provided that all requirements of this section are applied to the agent, collaborator, or contractor. Notwithstanding the foregoing, the health insurance organization or issuer may disclose information, without identifiers, to research organizations without the authorization of the covered persons.
(d) A health insurance organization or issuer shall disclose only the minimum data necessary to conduct the intended research.
(e) If the scientific, medical, or public policy research does not require contact with the individual who is the subject of the protected health information, the following protections shall exist prior to disclosure:
(1) The research organization develops and implements a written policy that includes procedures to assure the security and privacy of protected health information. The policy shall include:
(A) Training and disciplinary procedures to assure that persons involved in research comply with the provisions of this section;
(B) safeguards to assure that information in a report of the research project does not contain protected health information. The safeguards shall include a system for ensuring that only authorized individuals are able to establish a link between individuals and their health information, and
(C) a method for removing all information that identifies, directly or indirectly, the individual who is the subject of the protected health information, when the information is no longer needed for research. The policy may also provide that the research organization may retain the protected health information for an indefinite period if archived in an encoded form, and provided that it may not be used for other research unless the requirements of this section are met. “Encoded” means that the personally identifiable information is removed or encrypted and the key to restore the protected health information is retained in a secure place within the research organization with access limited to the minimum number of people necessary to maintain the confidentiality and integrity of the key.
(2)
(A) The research organization prepares a plan that explains the purposes of the research, includes a general description of research methods to be used, and describes the potential benefits of the research.
(B)
(i) All research plans using protected health information shall be available to the public and may be obtained by written request to the chief executive officer of the research organization.
(ii) If the research plan contains information that is proprietary or protected from disclosure by contract or statute, the information may be deleted from the copy made available to the public.
(iii) The research organization shall keep the research plan on file for five (5) years.
(3)
(A) The health insurance organization or issuer and the research organization shall execute a written agreement in which they agree to the following:
(i) Stating the purposes of the research;
(ii) explaining how the purposes qualify as scientific, medical or public policy research;
(iii) documenting that the research organization meets the requirements of this section;
(iv) stating the expected time during which the data will be used for the stated purposes;
(v) explaining the method of disposition of the protected health information at the end of the term of use; and
(vi) stating that the written agreement shall be available to the public and can be obtained by written request to the chief executive officer of the research organization.
(B) The health insurance organization or issuer shall require the research organization to provide a copy of the written agreement upon request to any person. If the executed agreement contains information that is proprietary or protected from disclosure by contract or law, the information may be deleted from the copy that is made available pursuant to this subsection.
(C) The health insurance organization or issuer shall keep this agreement on file five (5) years.
(f) If the scientific, medical or public policy research requires contact with the individual who is the subject of protected health information, the following protections shall exist prior to disclosure:
(1) The research organization and health insurance organization or issuer shall meet the requirements of subsection (e) of this section, and
(2)
(A) The research organization is responsible for obtaining a legally effective willful informed consent of the subject or the subject's legally authorized representative. A research organization shall seek consent only under circumstances that provide the prospective subject or the representative with sufficient opportunity to consider whether to participate in the research, and that minimize the possibility of coercion or undue influence.
(B) The information that is given to the subject or the representative shall be in language understandable to them.
(C) The document whereby a subject furnishes the informed consent may not include any exculpatory language through which the subject or the representative waives or appears to waive any of the subject's legal rights, or releases or appears to release the researcher, the sponsor, the research organization or its agents from liability or negligence.
(D) Basic elements of informed consent.— In seeking informed consent the following information shall be provided to each subject:
(i) A statement that the study involves research, an explanation of the purposes of the research and the expected duration of the subject's participation, a description of the procedures to be followed, and identification of any procedures that are experimental;
(ii) a description of any reasonably foreseeable risks or discomforts to the subject;
(iii) a description of any benefits to the subject or to others that may reasonably be expected from the research;
(iv) a disclosure of appropriate alternative procedures or treatments, if any, that might be advantageous to the subject;
(v) a statement describing the extent to which confidentiality of records identifying the subject will be maintained;
(vi) for research involving more than minimal risk, an explanation as to whether any compensation and medical treatments are available if injury occurs and, if so, what they consist of, or where further information may be obtained;
(vii) an explanation of whom to contact for answers to pertinent questions about the research and the research subject's rights;
(viii) the name of the person to contact in the event of a research-related injury to the subject, and
(ix) a statement that participation is voluntary, refusal to participate will involve no penalty or loss of benefits to which the subject is otherwise entitled, and that the subject may discontinue participation at any time without penalty or loss of benefits to which the subject is otherwise entitled.
(E) Additional elements of informed consent.— When appropriate, the following shall also be provided to each subject:
(i) A statement that the particular treatment or procedure may involve risks to the subject (or to the embryo or fetus, if the subject is or may become pregnant) that are currently unforeseeable;
(ii) foreseeable circumstances under which the subject's participation may be terminated by the investigator without regard to the subject's consent;
(iii) any additional costs to the subject that may result from participation in the research;
(iv) the consequences of a subject's decision to withdraw from the research and procedures for orderly termination of subject's participation in the research;
(v) a statement that significant new findings developed during the course of the research that may relate to the subject's willingness to continue participation will be provided to the subject, and
(vi) the approximate number of subjects involved in the study.
(F) If a research organization submits research for approval by an institutional review board under the Federal Policy for the Protection of Human Subjects—56 Federal Register 28000 (1991)—compliance with that process will be deemed compliance with the provisions of subsections (c)(2) and (f)(2) of this section.
(g)
(1) If a health insurance organization or issuer discloses to an organization health information that is not protected health information because all identifying information is encrypted, the health insurance organization or issuer and research organization shall execute a written agreement that provides:
(A) That the research organization will not disclose the data accompanied by the encrypted indentifying information to a third person. However, the research organization may disclose protected health information to its agents, collaborators, or contractors as needed to conduct or assist with the research, provided that all requirements of this section are applied to the agent, collaborator, or subcontractor;
(B) that the research organization shall make no efforts to link any health information it received with encrypted indentifying information to any other data that may identify the individual who is the subject of the information, and
(C) that the research organization shall make no efforts to link any encrypted protected health information with any other identifiable data.
(2) Prior to any encrypted information being decrypted or linked to identifying data, the research organization shall comply with the requirements set forth in this section and health information with decrypted identifying information shall be deemed protected health information.
(h) Nothing in this chapter shall be construed to prevent the creation, use, or disclosure of anonymized data for which there is no reasonable basis to believe that the information could be used to identify an individual.
(i) Nothing in this section shall be construed as superseding federal or Commonwealth laws and regulations governing scientific, medical, and public policy research.
History —Aug. 29, 2011, No. 194, added as § 14.120 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9243/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9243 - Unauthorized collection, use or disclosure of protected health information
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9243 - Unauthorized collection, use or disclosure of protected health information
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An unauthorized collection, use, or disclosure of protected health information by a health insurance organization or issuer is hereby prohibited. Such collection, use, or disclosure shall be subject to the penalties set forth in § 9245 of this title. An unauthorized collection, use, or disclosure shall include:
(a) Unauthorized publication of protected health information;
(b) unauthorized collection, use or disclosure of protected health information for personal or professional gain, including unauthorized research that does not meet the requirements of this chapter;
(c) unauthorized sale of protected health information;
(d) unauthorized manipulation of encrypted health information that reveals protected health information, and
(e) use of deception, fraud, or threat to procure authorization to collect, use or disclose protected health information.
History —Aug. 29, 2011, No. 194, added as § 14.130 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9244/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9244 - Right to limit disclosures
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9244 - Right to limit disclosures
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(a) A health insurance organization or issuer shall limit disclosure of information, including protected health information, if the individual subject of such information clearly states in writing that disclosure to specified individuals of all or part of that information could jeopardize his/her safety. Disclosure of information shall be limited consistent with the individual's request, such as a request for the health insurance organization or issuer to not release any information to a spouse to prevent domestic violence.
(b) Except as otherwise required by law, if the individual who is the subject of the protected health information makes a written request, a health insurance organization or issuer shall not disclose protected health information concerning health services related to reproductive health, sexually transmitted diseases, substance abuse and behavioral health, including mailing appointment notices, calling the home to confirm appointments, or mailing a bill or explanation of benefits to a policyholder or certificate holder. The written request shall include information as to how any amounts payable by the individual will be handled.
(c)
(1) A health insurance organization or issuer shall recognize the right of any minor who may obtain healthcare without the consent of a parent or legal guardian pursuant to Commonwealth or federal law, to exclusively exercise rights granted under this chapter regarding health information, and
(2) a health insurance organization or issuer shall not disclose any protected health information related to any healthcare service to which the minor has lawfully consented, including mailing appointment notices, calling the home to confirm appointments, or mailing a bill or explanation of benefits to a policyholder or certificate holder, without the express authorization of the minor.
History —Aug. 29, 2011, No. 194, added as § 14.140 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-112/9245/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 112 - Health Information Protection (§§ 9231 — 9245)›§ 9245 - Sanctions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9245 - Sanctions
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(a) Civil sanctions.—
(1) Whenever the Commissioner has reason to believe that a person has committed negligence in violation of the provisions of this chapter and that an action is in the public interest, the Commissioner may bring an action to enjoin such violations. An injunction issued under this section shall be issued without bond.
(2) In addition to the relief available pursuant to clause (1) of this subsection, the Commissioner may request and the court may order any other temporary or permanent relief as may be in the public interest, including any of the following, or any combination of the following:
(A) A civil penalty of not more than the thousand dollars ($10,000) for each violation, not to exceed fifty thousand dollars ($50,000) in the aggregate for multiple violations;
(B) a civil penalty of not more than two hundred fifty thousand dollars ($250,000) if the court finds that violations of this chapter have occurred with sufficient frequency, and
(C) reasonable attorney fees, investigation and court costs.
(b) Criminal sanctions.—
(1) The penalties described below shall apply to any natural or juridical person that collects, uses, or discloses protected health information in knowing violation of this chapter and the applicable privacy laws and regulations.
(2)
(A) A fine of not more than fifty thousand dollars ($50,000), imprisonment for not more than one (1) year; or both;
(B) If the violation is committed under false pretenses, a fine of not more than two hundred fifty thousand dollars ($250,000), imprisonment for not more than five (5) years, or any combination of these penalties, or
(C) if the violation is committed with the intent to sell, transfer or use protected health information for malicious harm, a fine of not more than five hundred thousand dollars ($500,000), imprisonment for not more than ten (10) years, or any combination of these penalties.
(c) In the event that a health insurance organization or issuer is being sued in connection with an unauthorized disclosure under a theory of vicarious liability for the actions or omissions of the health insurance organization or issuer's employees, it shall be an affirmative defense that the health insurance organization or issuer substantially met the requirements of § 9235 of this title.
History —Aug. 29, 2011, No. 194, added as § 14.150 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9271/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9271 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9271 - Title
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This chapter shall be known and may be cited as the chapter on Limited Health Service Organizations.
History —Aug. 29, 2011, No. 194, added as § 16.010 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9272/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9272 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9272 - Definitions
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For purposes of this chapter:
(a) Evidence of coverage.— Means a certificate, policy, agreement, or contract setting forth the coverage to which a subscriber is entitled.
(b) Limited health service organization.— Means any corporation, partnership or other entity that undertakes to provide or arrange for the provision of one (1) or more limited health services to subscribers in return for a prepayment which is deemed to be earned whether the individual uses the limited health services provided under the plan. Limited health service organization does not include:
(1) An entity that meets the requirements of § 9277 of this title, or
(2) a provider or entity when providing or arranging for the provision of limited health services pursuant to a contract with a limited health service organization or with an entity that complies with the provisions of clause (1) of this subsection.
(c) Provider.— Means a physician, dentist, hospital, healthcare facility, or other person or institution duly authorized in Puerto Rico to deliver or furnish limited health services.
(d) Limited health services.— Means dental care services, vision care services, mental health services, substance abuse services, pharmaceutical services, podiatric care services, and such other services as may be determined by the Commissioner to be limited health services. Limited health service shall not include hospital, medical, surgical or emergency services except as these services are provided incident to the limited health services set forth in the preceding sentence.
(e) Subscriber.— Means any person, including his/her dependents, who is entitled to received limited health services pursuant to a contract with an entity authorized to provide or arrange for such services.
History —Aug. 29, 2011, No. 194, added as § 16.020 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9273/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9273 - Certificate of authority required
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9273 - Certificate of authority required
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No person, corporation, partnership, or entity may operate a limited health service organization in Puerto Rico without obtaining a certificate of authority therefor from the Commissioner.
History —Aug. 29, 2011, No. 194, added as § 16.030 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9274/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9274 - Application for certificate of authority
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9274 - Application for certificate of authority
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An application for a certificate of authority to operate as a limited health service organization shall be filed with the Commissioner on a form prescribed by him/her. The application shall be sworn by an officer or authorized representative of the applicant and shall set forth or enclose the following documents:
(a) A copy of the applicant's basic organizational document, such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents and all amendments thereto.
(b) A copy of all corporate bylaws or similar documents, regulating the conduct of the applicant's internal affairs.
(c) A list of the names, addresses, official positions, and biographical information of the individuals who are responsible for conducting the applicant's affairs, including the members of the board of directors, board of trustees, executive committee, or other governing board or committee, the principal officers, and any person or entity owning or having the right to acquire ten percent (10%) or more of the voting securities of the applicant, and the partners or members in the case of a partnership or association.
(d) A statement generally describing the applicant, its facilities, personnel, and the limited health services to be offered.
(e) A copy of the form of any contract made or to be made between the applicant and any providers regarding the provision of limited health services to subscribers.
(f) A copy of the form of any contract made, or to be made between the applicant and any person listed in subsection (c) of this section.
(g) A copy of the form of any contract made or to be made between the applicant and any person, corporation, partnership or other entity for the performance on the applicant's behalf of any functions including administration, enrollment, investment management, and subcontracting for the provision of limited health services to subscribers.
(h) A copy of the form of any group contract that is to be issued to employers, unions, trustees, or other organizations and a copy of any form of evidence of coverage to be issued to subscribers.
(i) A copy of the applicant's most recent financial statements audited by independent certified public accountants. If the financial affairs of the applicant's parent company are audited by independent certified public accountants but those of the applicant are not, then a copy of the most recent audited financial statements of the applicant's parent company, enclosed with the consolidating financial statements of the applicant.
(j) A copy of the applicant's financial plan, including a three (3)-year projection of anticipated operating results, a statement of the sources of working capital, and any other sources of funding and provisions for contingencies.
(k) A description of the proposed method of marketing.
(l) A statement duly executed by the applicant, if not domiciled in Puerto Rico, designating the Commissioner and his/her successors in office as proxy to receive summons for causes of action that may arise against the applicant in Puerto Rico.
(m) A description of the grievance procedures to be established and maintained as required under § 9283 and §§ 9391 et seq. and 9501 et seq. of this title.
(n) A description of the quality assessment and utilization review procedures to be used by the applicant in accordance with §§ 9351 et seq. and 9421 et seq. of this title respectively.
(o) A description of how the applicant will comply with § 9288 of this title.
(p) The fee for issuance of a certificate of authority provided in § 9294 of this title.
(q) Such other information as the Commissioner may reasonably require to make the determinations required by this chapter.
History —Aug. 29, 2011, No. 194, added as § 16.040 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9275/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9275 - Issuance or denial of certificate of authority
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9275 - Issuance or denial of certificate of authority
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(a) The Commissioner shall issue or deny a certificate of authority to any applicant that files an application pursuant to § 9274 of this title. The Commissioner shall issue a certificate of authority provided that the following conditions are met:
(1) The requirements of § 9274 of this title have been fulfilled.
(2) The individuals responsible for conducting the applicant's affairs are competent, trustworthy, and possess good reputations, and have had appropriate experience, training, or education.
(3) The applicant is financially sound. In making this determination, the Commissioner may consider:
(A) The financial soundness of the applicant's arrangements for the provision of limited health services, and the minimum standard rates, deductibles, copayments, and other patient charges used in connection therewith;
(B) the adequacy of working capital, other sources of funding, and provisions for contingencies;
(C) any agreement for paying the cost of the limited health services or for alternative coverage in the event of insolvency of the limited health service organization, and
(D) the manner in which the requirements of § 9288 of this title will be fulfilled.
(4) The agreements with providers for the provision of limited health services contain the provisions required by § 9287 of this title.
(5) Any deficiencies identified by the Commissioner have been corrected.
(b) If the certificate of authority is denied, the Commissioner shall notify the applicant and shall specify the reasons for denial in the notice. The applicant shall have twenty (20) days from the date of receipt of the notice to request a hearing before the Commissioner.
History —Aug. 29, 2011, No. 194, added as § 16.050 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9276/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9276 - Effect on organizations operating on effective date of this chapter
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9276 - Effect on organizations operating on effective date of this chapter
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Within ninety (90) days after the effective date of this chapter, every limited health service organization operating in Puerto Rico without a certificate of authority shall submit an application for a certificate of authority to the Commissioner pursuant to the provisions of § 9274 of this title. Such organization may continue to operate during the pendency of its application. In the event an application is denied, the applicant will then be treated as a limited health service organization whose certificate of authority has been revoked.
History —Aug. 29, 2011, No. 194, added as § 16.060 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9277/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9277 - Filing requirements for authorized entities
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9277 - Filing requirements for authorized entities
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(a) A health service organization, a disability insurance company, a nonprofit health, hospital or medical service organization, or a fraternal benefit society may file for approval with the Commissioner a request to offer limited health services by submitting the information described in subsections (d), (e), (g), (h), (j), (k), (l), and (o) of § 9274 of this title and any additional document that the Commissioner may request.
(b) If the Commissioner disapproves the filing, the procedures set forth in § 9275(b) of this title shall be followed.
History —Aug. 29, 2011, No. 194, added as § 16.070 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9278/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9278 - Changes and material modifications; addition of limited health services
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9278 - Changes and material modifications; addition of limited health services
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(a) A limited health service organization shall file with the Commissioner prior to use, a notice of any intended change in rates, charges, or benefits and of any material modification of operations or information furnished pursuant to § 9274 of this title. Such filing shall be made within sixty (60) days before the change. Once the sixty (60)-day term elapses, the change shall be deemed to be approved, unless it is expressly approved or disapproved by order of the Commissioner. The Commissioner may, upon previous notification, extend such term for sixty (60) additional days, within which he/she may approve or disapprove the change.
(b) If a limited health service organization desires to provide additional limited health services, it shall file a notice with the Commissioner and, at the same time, shall submit the information required by § 9274 of this title and shall comply with §§ 9287, 9288 and 9294 of this title.
(c) If such filings are denied, the procedure set forth in § 9275(b) of this title shall be followed.
History —Aug. 29, 2011, No. 194, added as § 16.080 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9279/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9279 - Evidence of coverage
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9279 - Evidence of coverage
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(a) Every limited health service organization shall issue an evidence of coverage to each one of its subscribers, which shall contain a clear and complete statement of:
(1) The limited health services to which each subscriber is entitled;
(2) any limitation of the services, kinds of services or benefits to be provided, and exclusions, including any deductible, copayment or other charges;
(3) the manner information shall be made available and where and how services may be obtained, and
(4) the method for resolving grievances.
(b) Any amendment to the evidence of coverage may be provided to the subscriber in a separate document.
(c) No evidence of coverage or amendment thereto shall be issued or delivered to any person in Puerto Rico, unless it has been previously filed with the Commissioner and approved by him/her. Each one of such filings shall be made within at least sixty (60) days prior to their issuance, delivery, or use. Once the sixty (60)-day term, from the date such filings are received in the Office of the Commissioner, elapses, the filing shall be deemed approved, unless it is expressly approved or disapproved by order of the Commissioner. The approval of an evidence of coverage by the Commissioner shall waive any waiting period left. The Commissioner may extend for not more than sixty (60) days, the period within which such evidence of coverage may be expressly approved or disapproved, providing a notice of such extension before the initial sixty (60)-day term elapses. If the Commissioner determines that the information furnished is not sufficient, or the evidence of coverage provided does not comply with any of the provisions of this chapter or the regulations thereunder and, therefore, requests additional information, the period of time from the notification of the Commissioner of such requirement to the receipt of the requested information or amendments by the Commissioner, shall not be counted for purposes of computing the aforementioned terms. To determine whether an evidence of coverage is approved or disapproved, the Commissioner may require the submittal of any relevant information that he/she may deem pertinent.
(d) If the Commissioner disapproves the filing, the Commissioner shall notify the applicant and shall specify the reasons for disapproval in the notice. The applicant shall have twenty (20) days from the date of receipt of the notice to request a hearing before the Commissioner.
(e) Any time after the applicable review period as provided in subsection (c) of this section, the Commissioner may hold a hearing to determine whether the filing meets the established requirements. The Commissioner shall provide a notice in writing to the limited health service organization that made the filing at least ten (10) days before the hearing. If, after the hearing, the Commissioner determines that the filing does not meet the requirements of this Section, he/she shall enter an order specifying the reasons for disapproval and the date, within a reasonable subsequent period, on which the filing shall be deemed to be ineffective. Such order shall not affect any agreement executed or ratified before the expiration of the term specified in the order.
History —Aug. 29, 2011, No. 194, added as § 16.090 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9280/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9280 - Rates and charges
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9280 - Rates and charges
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(a) The rates for a limited health service plan to be used by a limited health service organization shall be filed with the Commissioner, before applying them in Puerto Rico. No filing shall be effective until sixty (60) days after the receipt thereof in the Office of the Commissioner, unless it is expressly approved by the Commissioner. The Commissioner may extend such period for an additional term that shall not exceed sixty (60) days, if the Commissioner notifies the applicant within such waiting period. If the Commissioner determines that the information provided in the filing is not sufficient and, therefore, requires additional information, the period of time from the notification of the Commissioner of such requirement to the receipt of the requested information by the Commissioner shall not be counted for purposes of computing the aforementioned terms. To determine whether a rate is approved or disapproved, the Commissioner may require the submittal of any relevant information that he/she may deem pertinent.
(b) Rates shall be established in accordance with the actuarial principles for various categories of subscribers. Charges applicable to a subscriber shall not be individually determined based on health status. Rates shall not be excessive, inadequate, or discriminatory. A certification by a qualified actuary, to the appropriateness of the rates, based on reasonable assumptions shall be enclosed with the filing, along with adequate supporting information.
(c) If the Commissioner disapproves the filing, the Commissioner shall notify the applicant and shall specify the reasons for disapproval. The affected party shall have twenty (20) days from the date of receipt of the notice to request a hearing.
Any time after the applicable review period as provided in subsection (a) of this section, the Commissioner may hold a hearing to determine whether the filing meets the established requirements. The Commissioner shall provide a notice in writing to the limited health service organization that made the filing at least ten (10) days before the hearing. If, after the hearing, the Commissioner determines that the filing does not meet the requirements of this Section, he/she shall enter an order specifying the reasons for disapproval and the date, within a reasonable subsequent period, on which the filing shall be deemed to be ineffective. Such order shall not affect any agreement executed or ratified before the expiration of the term specified in the order.
History —Aug. 29, 2011, No. 194, added as § 16.100 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9281/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9281 - Construction with other laws
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9281 - Construction with other laws
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(a)
(1) A limited health service organization organized under the laws of Puerto Rico shall be deemed to be a domestic insurer for purposes of insurance holding companies regulations, unless specifically exempted in writing from one (1) or more of the provisions of such regulations by the Commissioner.
(2) A limited health service organization shall be subject to the provisions of §§ 2701 et seq. of this title.
(b) The provision of limited health services by a limited health service organization shall not be deemed to be the practice of medicine or other healing arts.
History —Aug. 29, 2011, No. 194, added as § 16.110 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9282/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9282 - Nonduplication of coverage
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9282 - Nonduplication of coverage
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A limited health service organization, health service organization, disability insurance company, nonprofit health, hospital or medical service organizations may exclude, in any contract or policy, any coverage that would duplicate the coverage for limited health services.
History —Aug. 29, 2011, No. 194, added as § 16.120 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9283/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9283 - Grievance system
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9283 - Grievance system
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Every limited health service organization shall establish and maintain a grievance system as provided in §§ 9391 et seq. and 9501 of this title, which shall be approved by the Commissioner and provide reasonable procedures for resolving written grievances initiated by subscribers and providers related to the provisions of the limited health service plan. Nothing herein shall be construed to preclude a subscriber or a provider from filing a grievance with the Commissioner or as limiting the Commissioner's ability to investigate such grievances.
History —Aug. 29, 2011, No. 194, added as § 16.130 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9284/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9284 - Examination
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9284 - Examination
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(a) The Commissioner may examine the affairs of any limited health service organization and providers with which such organization maintains contracts, agreements or other arrangements, at least every three (3) years.
(b) Every limited health service organization and provider shall make its relevant books and records available for an examination and in every way cooperate with the Commissioner to facilitate an examination. For examination purposes, the Commissioner may administer oaths and examine the officials and agents of the organization and of the providers.
(c) The reasonable expenses of an examination under this section shall be charged to the organization being examined and remitted to the Commissioner.
(d) In the case of foreign limited health service organizations, the Commissioner may accept the report of an examination made by the Commissioner of the organization's state of domicile.
History —Aug. 29, 2011, No. 194, added as § 16.140 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9285/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9285 - Investments
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9285 - Investments
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The funds of a limited health service organization shall be invested only in securities and other investments allowed by the laws of Puerto Rico for the investment of assets that constitute the legal reserve of life issuers or other securities or investments that the Commissioner may allow.
History —Aug. 29, 2011, No. 194, added as § 16.150 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9286/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9286 - Authorized representatives
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9286 - Authorized representatives
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(a) No limited health service organization shall engage in procurement and underwriting activities, if not by an authorized representative of such organization.
(b) The provisions related to licensing, commissions, requirements, examination, controlled businesses, bonds, summons, books, documents, and reports of §§ 949 et seq. of this title shall apply to limited health service organizations intermediaries.
History —Aug. 29, 2011, No. 194, added as § 16.160 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9287/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9287 - Contracts with providers
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9287 - Contracts with providers
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All contracts with providers for the provision of limited health services to subscribers shall contain the following terms and conditions:
(a) In the event the limited health service organization fails to pay a provider for rendering services to a subscriber, including insolvency or breach of contract or any other reason, the subscribers shall not be liable to the contracted provider for any sums owed.
(b) No provider, agent, trustee, or assignee thereof may initiate an action at law or attempt to collect from the subscriber sums owed to the provider by the limited health service organization.
(c) These provisions do not prohibit collection of charges not covered by the limited health service organization to the subscriber such as copayments, deductibles, or coinsurance, provided that it has been agreed upon in the contract or policy between the limited health service organization and the subscriber.
(d) The provisions of this section shall remain in effect regardless of the termination of a contract between the limited health service organization and the subscriber and the reasons for such termination.
(e) Termination of the contract between the limited health service organization and the provider shall not exempt the provider from completing procedures in progress on subscribers then receiving treatment for a specific condition for a period not to exceed thirty (30) days, subject to the same copayment or other applicable charge in effect upon the effective date of termination of the contract. This period of time shall only apply in those cases in which a transition period for the continuation of services for subscribers as a result of the termination of a contract between the limited health service organization and the provider has not been provided under federal or Commonwealth law.
History —Aug. 29, 2011, No. 194, added as § 16.170 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9288/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9288 - Protection against insolvency; deposit
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9288 - Protection against insolvency; deposit
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(a) Except as approved in accordance with subsection (d) of this section, each limited health service organization shall at all times have and maintain tangible net equity equal to the greater of fifty thousand dollars ($50,000); or two percent (2%) of the organization's annual gross premium income.
(b) For purposes of this section, “net equity” means the excess of total assets over total liabilities, excluding liabilities which have been subordinated in a manner acceptable to the Commissioner. “Tangible net equity” means equity reduced by the value assigned to intangible assets including, but not limited to, goodwill; going concern value; organizational expense; starting-up costs; long-term prepayments of deferred charges; nonreturnable deposits; and obligations of officers, directors, owners, or affiliates, except short-term obligations of affiliates for goods or services arising in the normal course of business that are payable on the same terms as equivalent transactions with nonaffiliates and that are not past due.
(c)
(1) At the time of approval, each limited health service organization shall deposit with the Commissioner assets eligible for deposit in the amount of six hundred thousand dollars ($600,000), as provided in § 802 of this title.
(2) The deposit shall be an admitted asset of the limited health service organization in the determination of tangible net equity.
(3) All income from deposits shall be an asset of the limited health service organization. A limited health service organization may withdraw a deposit or any part thereof after making a substitute deposit of equal amount and value. Any securities shall be approved by the Commissioner before being substituted.
(4) The deposit shall be used to protect the interests of subscribers and to assure continuation of limited healthcare services to subscribers of a limited health service organization that is in rehabilitation. If a limited health service organization is placed in receivership or liquidation, the deposit shall be an asset subject to provisions applicable to a liquidation process.
(d) Upon application by a limited health service organization, the Commissioner may waive some or all of the requirements of subsection (a) of this section for any period of time the Commissioner deems proper if the limited health service organization has a net equity of at least five million dollars ($5,000,000).
History —Aug. 29, 2011, No. 194, added as § 16.180 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9289/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9289 - Officers and employees fidelity bond
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9289 - Officers and employees fidelity bond
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(a) A limited health service organization shall maintain in force a fidelity bond in its own name on its officers and employees in an amount not less than fifty thousand dollars ($50,000) or in any other amount prescribed by the Commissioner.
(b) In lieu of the bond requirement, a limited health service organization may deposit with the Commissioner cash, securities or other investments of the types set forth in § 9285 of this title. Such deposit shall be in the amount required for a bond.
History —Aug. 29, 2011, No. 194, added as § 16.190 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9290/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9290 - Annual reports
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9290 - Annual reports
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(a) Every limited health service organization shall file with the Commissioner, on or before March 31 of each year, an exact report covering the preceding calendar year, certified by a certified public accountant and signed under oath by two (2) principal officers.
(b) The report shall be on forms prescribed by the Commissioner and shall include:
(1) A financial statement of the organization, including its balance sheet, income and loss statement, and a statement of sources and application of funds for the preceding year;
(2) the number of subscribers at the beginning of the year, the number of subscribers as of the end of the year, and the number of enrollments terminated during the year;
(3) any material change to the information submitted in accordance with § 9274 of this title, and
(4) such other information related to the performance of the organization as is necessary to enable the Commissioner to carry out his/her duties under this chapter.
(c) The Commissioner may require more frequent reports containing such information as is necessary to enable the Commissioner to carry out his/her duties under this chapter.
(d) The Commissioner may assess a fine of up to one hundred dollars ($100) per day for each day any required report is late, and suspend the organization's certificate of authority pending the proper filing of the required report by the organization.
History —Aug. 29, 2011, No. 194, added as § 16.200 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9291/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9291 - Suspension or revocation of certificate of authority
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9291 - Suspension or revocation of certificate of authority
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(a) The Commissioner may suspend or revoke the certificate of authority issued to a limited health service organization pursuant to this chapter upon determining that any of the following conditions exist:
(1) The limited health service organization is operating significantly in contravention of its basic organizational document;
(2) the limited health service organization issues an evidence of coverage or uses rates or charges that do not meet the requirements of §§ 9279 and 9280 of this title;
(3) the limited health service organization is unable to fulfill its obligations to furnish limited health services;
(4) the limited health service organization is not financially sound and may reasonably be expected to be unable to meet its obligations to subscribers or prospective subscribers;
(5) the tangible net equity of the limited health service organization is less than required under § 9288 of this title, or such organization has failed to correct any deficiency in its tangible net equity as required by the Commissioner;
(6) the limited health service organization has failed to implement in a reasonable manner the grievance system required under § 9283 of this title;
(7) the continued operation of the limited health service organization would be hazardous to its subscribers;
(8) the limited health service organization has otherwise failed to comply with this Code, the Insurance Code of Puerto Rico, rule, regulation, or lawful order of the Commissioner, or
(9) the organization or any person acting on its behalf has advertised or marketed its services in a deceitful, unfair, or misleading manner.
(b) If the Commissioner has cause to believe that grounds for the suspension or revocation of a certificate of authority exist, he/she shall notify the limited health service organization in writing specifically stating the grounds for suspension or revocation and fixing the date not more than thirty (30) days thereafter for a hearing.
(c) When the certificate of authority of a limited health service organization is revoked, the organization shall proceed immediately to wind up its affairs, and shall conduct no further business except as may be essential to the orderly cease of operations. It shall engage in no further advertising or solicitation whatsoever. The Commissioner may, by written order, permit such further operation of the organization as he/she may find to be in the best interest of subscribers, to the end that subscribers will be afforded the greatest practical opportunity to obtain continuing limited health services.
History —Aug. 29, 2011, No. 194, added as § 16.210 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9292/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9292 - Additional sanctions for violations
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9292 - Additional sanctions for violations
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In addition to the suspension or revocation of the certificate of authority or in lieu of such penalty, a limited health service organization which has violated any provision of this Code, the Insurance Code of Puerto Rico, rule, regulation, or lawful order of the Commissioner, may be imposed the sanctions or penalties prescribed for issuers.
History —Aug. 29, 2011, No. 194, added as § 16.220 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9293/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9293 - Rehabilitation or liquidation
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9293 - Rehabilitation or liquidation
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(a) Any rehabilitation or liquidation of a limited health service organization shall be deemed to be the rehabilitation or liquidation of an issuer and shall be conducted under the supervision of the Commissioner by virtue of the Insurance Code of Puerto Rico on rehabilitation or liquidation. The Commissioner may request the court to enter an order for rehabilitation, liquidation or any other applicable remedy, or when in his/her judgment the continued operation of the organization would be hazardous to its subscribers or the public interest.
(b) A limited health service organization shall not be subject to the laws and regulations governing insurance insolvency guaranty funds, nor shall any insurance insolvency guaranty fund provide protection to individuals entitled to receive limited health services from a limited health service organization.
History —Aug. 29, 2011, No. 194, added as § 16.230 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9294/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9294 - Filing fees
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9294 - Filing fees
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Every limited health service organization shall pay to the Commissioner the established fees for the following:
(a) For filing an application for a certificate of authority or amendment thereto;
(b) for filing a material modification of or an addition to a limited health service;
(c) for filing each annual report, and
(d) for filing periodic reports as required by the Commissioner.
History —Aug. 29, 2011, No. 194, added as § 16.240 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9295/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9295 - Confidentiality
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9295 - Confidentiality
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(a) Any information obtained by a limited health service organization from the subscriber or a provider pertaining to the diagnosis, treatment or health of the subscriber shall be deemed confidential and shall not be disclosed to any person except:
(1) To the extent that it may be necessary to carry out the purposes of this chapter;
(2) upon the express consent of the subscriber or provider, as appropriate;
(3) pursuant to a statute or court order for the production of evidence or the discovery thereof, or
(4) in the event of claim or litigation wherein the data or information is relevant.
(b) A limited health service organization shall be entitled to claim any statutory privileges against disclosure that a provider is entitled to claim with respect to any information pertaining to the diagnosis, treatment, and health of any subscriber or applicant.
(c) In addition, any information provided to the Commissioner that constitutes a trade secret, or privileged information, or is part of an investigation shall be deemed to be confidential.
History —Aug. 29, 2011, No. 194, added as § 16.250 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-114/9296/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296)›§ 9296 - Taxes
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9296 - Taxes
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The same taxes provided for health service organizations shall be imposed upon each limited health service organization. Such organizations shall be entitled to the same tax deductions, reductions, and credits that health service organizations are entitled to receive.
History —Aug. 29, 2011, No. 194, added as § 16.260 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-116/9321/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328)›§ 9321 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9321 - Title
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This chapter shall be known and may be cited as the chapter on Healthcare Professionals or Entities Credentialing Verification.
History —Aug. 29, 2011, No. 194, added as § 18.010 on Aug. 23, 2012, No. 203, § 3, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-116/9322/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328)›§ 9322 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9322 - Purpose
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The purpose of this chapter is to require health insurance organizations or issuers to establish a comprehensive healthcare professional or entity credentialing verification program to ensure that participating healthcare professionals meet specific minimum standards of professional or licensing qualifications. The standards set out in this chapter address the initial credentialing verification and subsequent re-credentialing thereof.
History —Aug. 29, 2011, No. 194, added as § 18.020 on Aug. 23, 2012, No. 203, § 3, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-116/9323/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328)›§ 9323 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9323 - Definitions
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For purposes of this chapter:
(a) Credentialing verification.— Is the process of obtaining and verifying information about a healthcare professional or entity, and evaluating that healthcare professional or entity, when such healthcare professional or entity applies to become a participating provider in a managed care plan offered by a health insurance organization or issuer.
(b) Primary verification.— Means verification by the health insurance organization or issuer of a healthcare professional or entity's credentials based upon evidence obtained directly from the issuing source of the credential.
(c) Secondary verification.— Means verification by the health insurance organization or issuer of a healthcare professional's credentials based upon evidence obtained by means other than direct contact with the issuing source of the credential (e.g., copies of certificates provided by the applying healthcare professional).
History —Aug. 29, 2011, No. 194, added as § 18.030 on Aug. 23, 2012, No. 203, § 3, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-116/9324/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328)›§ 9324 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9324 - Applicability and scope
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This chapter shall apply to health insurance organizations or issuers that offer managed care plans.
History —Aug. 29, 2011, No. 194, added as § 18.040 on Aug. 23, 2012, No. 203, § 3, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-116/9325/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328)›§ 9325 - General responsibilities of health insurance organizations or issuers
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9325 - General responsibilities of health insurance organizations or issuers
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(a) A health insurance organization or issuer shall:
(1) Establish written policies and procedures for credentialing verification of all healthcare professionals or entities with which the health insurance organization or issuer contracts and apply these standards consistently;
(2) verify the credentials of a healthcare professional or entity before entering into a contract with the same. The medical director of the health insurance organization or issuer or other designated healthcare professional shall have responsibility for, and shall participate in, healthcare professional credentialing verification;
(3) establish a credentialing verification committee consisting of licensed physicians and other healthcare professionals to review credentialing verification information and supporting documents and make decisions regarding credentialing verification;
(4) make available for review by the applying healthcare professional upon written request all application and credentialing verification policies and procedures;
(5) retain all records and documents relating to a healthcare professional's credentialing verification process for at least three (3) years, and
(6) keep confidential all information obtained in the credentialing verification process, except as otherwise provided by law.
(b) Nothing in this chapter shall be construed to require a health insurance organization or issuer to enter into contract with a provider as a participating provider solely because the provider meets the health insurance organization or issuer's credentialing verification standards, or to prevent a health insurance organization or issuer from utilizing additional criteria in selecting the healthcare professionals with whom it contracts.
History —Aug. 29, 2011, No. 194, added as § 18.050 on Aug. 23, 2012, No. 203, § 3, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-116/9326/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328)›§ 9326 - Verification responsibilities of health insurance organizations or issuers
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9326 - Verification responsibilities of health insurance organizations or issuers
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A health insurance organization or issuer shall:
(a) Obtain primary verification of at least the following information about the applicant:
(1) Current license, certificate of authority or registration to practice his/her profession in Puerto Rico;
(2) meets financial responsibility requirements;
(3) status of hospital privileges (if applicable);
(4) specialty board certification status (if applicable);
(5) current Drug Enforcement Agency (DEA) registration certificate (if applicable);
(6) graduation from an accredited professional school, and
(7) completion of post graduate training (if applicable).
(b) Obtain, subject to either primary or secondary verification at the health insurance organization or issuer's discretion:
(1) The healthcare professional's license history in Puerto Rico and all other states;
(2) the healthcare professional's malpractice history, and
(3) the healthcare professional's practice history.
(c) At least every three (3) years, obtain primary verification of a participating healthcare professional's:
(1) Current license, certificate of authority or registration to practice his/her profession in Puerto Rico;
(2) meets financial responsibility requirements;
(3) status of hospital privileges (if applicable);
(4) current DEA registration certificate (if applicable), and
(5) specialty board certification status (if applicable).
(d) Require all participating providers to notify the health insurance organization or issuer of changes in the status of any of the items listed in this section and indicate to the participating providers the contact information to report such changes.
History —Aug. 29, 2011, No. 194, added as § 18.060 on Aug. 23, 2012, No. 203, § 3, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-116/9327/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328)›§ 9327 - Healthcare professional's right to review credentialing verification information
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9327 - Healthcare professional's right to review credentialing verification information
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A health insurance organization or issuer shall provide a healthcare professional or entity the opportunity to review and correct information submitted in support of his/her credentialing verification application as set forth below.
(a) Each healthcare professional or entity that is subject to the credentialing verification process shall have the right to review all information, including the source of that information, obtained by the health insurance organization or issuer during the credentialing process.
(b) A health insurance organization or issuer shall notify a healthcare professional of any information obtained that does not meet its credentialing verification standards or that varies substantially from the information provided by the healthcare professional or entity. Notwithstanding the foregoing, the health insurance organization or issuer shall not be required to reveal the source of information, if such disclosure is prohibited by law.
(c) A healthcare professional or entity shall have the right to correct any erroneous information. A health insurance organization or issuer shall have a formal process whereby a healthcare professional or entity may submit supplemental or corrected information to the credentialing verification committee and request reconsideration, if the healthcare professional or entity believes that the committee has received information that is incorrect, misleading or erroneous. Supplemental information shall be subject to confirmation by the health insurance organization or issuer.
History —Aug. 29, 2011, No. 194, added as § 18.070 on Aug. 23, 2012, No. 203, § 3, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-116/9328/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328)›§ 9328 - Contracting
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 116 - Healthcare Professionals or Entities Credentialing Verification (§§ 9321 — 9328) › § 9328 - Contracting
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Whenever a health insurance organization or issuer contracts to have another entity perform the credentialing functions required by this chapter, the Commissioner shall hold the health insurance organization or issuer responsible for monitoring the activities of the entity with which it contracts.
History —Aug. 29, 2011, No. 194, added as § 18.080 on Aug. 23, 2012, No. 203, § 3, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-118/9351/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360)›§ 9351 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9351 - Title
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This chapter shall be known and may be cited as the Health Insurance Organization or Issuer Quality Assessment and Improvement.
History —Aug. 29, 2011, No. 194, added as § 20.010 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-118/9352/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360)›§ 9352 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9352 - Purpose
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This chapter establishes criteria for the quality assessment and quality improvement activities of all health insurance organizations or issuers that offer managed care plans. The purpose of establishing such criteria is to enable health insurance organizations or issuers to evaluate, maintain and improve the quality of healthcare services provided to covered person or enrollee or enrollees.
History —Aug. 29, 2011, No. 194, added as § 20.020 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-118/9353/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360)›§ 9353 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9353 - Definitions
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(a) Consumer.— Means someone in the general public who may or may not be a covered person or enrollee or enrollee or a purchaser of healthcare services, including employers.
(b) Quality assessment.— Means the measurement and evaluation of the quality and outcomes of medical care provided to individuals, groups or populations.
(c) Quality improvement.— Means the effort to improve the processes and outcomes related to the provision of healthcare services within the health plan.
History —Aug. 29, 2011, No. 194, added as § 20.030 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-118/9354/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360)›§ 9354 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9354 - Applicability and scope
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Except as otherwise specified, this chapter shall apply to all health insurance organizations or issuers that offer managed care plans.
History —Aug. 29, 2011, No. 194, added as § 20.040 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-118/9355/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360)›§ 9355 - Quality assessment standards
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9355 - Quality assessment standards
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Any health insurance organization or issuer that provides managed care plans shall develop and maintain the infrastructure and disclosure systems necessary to measure the quality of healthcare services provided to covered person or enrollees or enrollees on a regular basis and appropriate to the types of plans offered by it. For such purposes, a health insurance organization or issuer shall:
(a) Establish a system designed to assess the quality of healthcare services provided to covered person or enrollees or enrollees. Such system shall be appropriate to the types of plans offered by the health insurance organization or issuer.
(b) Communicate the findings of the quality assessment and improvement program in a timely manner to applicable regulatory agencies, including the Commissioner, providers and consumers, as provided in § 9358 of this title.
(c) Report to the applicable regulatory agencies, including the Commissioner, any persistent pattern of problematic care provided by a provider that is sufficient to cause the health insurance organization or issuer to terminate or suspend contractual arrangements with such provider. A health insurance organization or issuer shall not be held liable, for complying with the duties imposed onto it by this provision.
(d) File with the Commissioner in the prescribed format a description of the quality assessment program, which shall include a signed certification by a corporate officer of the health insurance organization or issuer that the filing meets the requirements of this chapter.
History —Aug. 29, 2011, No. 194, added as § 20.050 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-118/9356/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360)›§ 9356 - Quality improvement standards for closed plans
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9356 - Quality improvement standards for closed plans
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In addition to meeting the requirements of § 9355 of this title, a health insurance organization or issuer that issues a closed plan, or a combination plan having a closed component, shall develop and maintain the internal structures and activities necessary to improve the quality of its services as required by this section. For such purposes, a health insurance organization or issuer shall:
(a) Establish an internal system to identify opportunities to improve the healthcare services provided. This system shall be structured to identify: practices that result in improved healthcare, identify problematic utilization patterns, identify those providers that may be responsible for either exemplary or problematic patterns, and foster an environment of continuous quality improvement.
(b) Use the findings generated by the system to work, on a continuing basis, with participating providers and other staff within the health plan to improve the healthcare services delivered to covered persons or enrollees.
(c) Develop and maintain a program for designing, measuring, assessing, and improving the processes and outcomes of healthcare as identified in the health insurance organization or issuer's quality improvement program filed with the Commissioner. This program shall be under the direction of the medical or clinical staff of the health insurance organization or issuer and must include:
(1) A written statement of the objectives, lines of authority and accountability, evaluation tools, (including data collection responsibilities,) performance improvement activities and an annual effectiveness review of the quality improvement program.
(2) A written quality improvement plan that describes how the health insurance organization or issuer intends to:
(A) Analyze both processes and outcomes of healthcare, including focused review of individual cases as appropriate, to discern the causes of variation.
(B) Identify the targeted diagnoses and treatments to be reviewed by the quality improvement program each year. In determining which diagnoses and treatments to target for review, the health insurance organization or issuer shall consider practices and diagnoses that affect or could pose a risk to a substantial number of the plan's covered persons or enrollees. The foregoing shall not be construed to require a health insurance organization or issuer to review every disease, illness, and condition that may affect a member of a managed care plan.
(C) Use a range of appropriate methods to analyze the quality of service, including:
(i) Collection and analysis of information on over- utilization and under-utilization of services.
(ii) Evaluation of courses of treatment and outcomes of healthcare.
(iii) Collection and analysis of information specific to a covered person or enrollee or provider, gathered from multiple sources such as utilization management organizations, and claims processing, among others.
(D) Compare program findings with past performance, as appropriate, and with internal goals and external standards, where available, adopted by the health insurance organization or issuer.
(E) Measure the performance of participating providers and conduct peer review activities, such as:
(i) Identifying practices that do not meet the health insurance organization or issuer's standards;
(ii) taking appropriate action to correct deficiencies;
(iii) monitoring participating providers to determine whether they have implemented corrective action, and
(iv) taking appropriate action when the participating provider has not implemented corrective action.
(F) Utilize treatment protocols and practice parameters developed with appropriate clinical input and using the evaluations described in paragraphs (A) and (B) of this clause, or utilize acquired treatment protocols developed with appropriate clinical input; and provide participating providers with sufficient information about the protocols to enable participating providers to meet the standards established by these protocols.
(G) Evaluate access to healthcare services for covered persons or enrollees according to standards established by statute, regulation or the Commissioner. The quality improvement plan shall describe the health insurance organization or issuer's strategy for integrating public health goals with healthcare services offered, including a description of the health insurance organization or issuer's good faith efforts to initiate or maintain communication with public health agencies.
(H) Implement improvement strategies related to program findings.
(I) Evaluate periodically, but not less than annually, the effectiveness of the strategies implemented in paragraph (H) of this clause.
(d) Assure that participating providers have the opportunity to participate in developing, implementing, and evaluating the quality improvement system.
(e) Provide covered persons or enrollees the opportunity to comment on the quality improvement process.
History —Aug. 29, 2011, No. 194, added as § 20.060 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-118/9357/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360)›§ 9357 - Corporate oversight
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9357 - Corporate oversight
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The chief medical officer or clinical director of the health insurance organization or issuer shall have primary responsibility for the quality assessment and quality improvement activities carried out by, or on behalf of, the health insurance organization or issuer. Furthermore, such chief medical officer or clinical director shall ensure that all requirements of this chapter are met. The chief medical officer or clinical director shall approve the written quality assessment and quality improvement programs, as applicable, implemented in compliance with this chapter, and shall periodically review and revise them. Not less than twice (2) every year, the chief medical officer or clinical director shall review reports of quality assessment and quality improvement activities. The Commissioner shall hold the health insurance organization or issuer responsible for the actions of the chief medical officer or clinical director. Also, the health insurance organization or issuer shall be responsible for ensuring that all requirements of this chapter are met.
History —Aug. 29, 2011, No. 194, added as § 20.070 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-118/9358/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360)›§ 9358 - Reporting and disclosure requirements
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9358 - Reporting and disclosure requirements
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(a) As specified below, every health insurance organization or issuer shall document and communicate information about its quality assessment program and quality improvement program, if it has one, and shall:
(1) Include a summary of its quality assessment and quality improvement programs in marketing materials;
(2) include a description of its quality assessment and quality improvement programs and a statement of patient rights and responsibilities with respect to those programs in the certificate of coverage or handbook provided to newly enrolled covered persons or enrollees, and
(3) make available once (1) every year to providers and covered persons or enrollees the findings from its quality assessment and quality improvement programs and information about its progress in meeting internal goals and external standards, where available. The reports shall include a description of the methods used to assess each specific area.
(b)
(1) A health insurance organization or issuer shall certify to the Commissioner annually that its quality assessment program and quality improvement program, along with the materials provided to providers and consumers in accordance with subsection (a) of this section, meet the requirements of this chapter.
(2) A health insurance organization or issuer shall make available for review by the public upon request, subject to a reasonable fee, the materials certified in clause (1) of this subsection, except for the materials subject to the confidentiality requirements of § 9359 of this title, and materials that are proprietary to the health plan. A health insurance organization or issuer shall retain all certified materials for at least three (3) years from the date the material has been used or until the material has been examined as part of a market conduct examination, whichever comes first.
History —Aug. 29, 2011, No. 194, added as § 20.080 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-118/9359/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360)›§ 9359 - Confidentiality
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9359 - Confidentiality
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(a) Data or information pertaining to the diagnosis, treatment or health of a covered person or enrollee is confidential and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of this chapter and as allowed by the laws of Puerto Rico and the United States of America; or upon the express consent of the covered person or enrollee; or pursuant to statute or court order for the production of evidence or the discovery thereof; or in the event of a claim or litigation between the covered person or enrollee and the health insurance organization or issuer. If any data or information pertaining to the diagnosis, treatment, or health of any existing or potential covered person or enrollee is disclosed pursuant to the provisions of this section, the health insurance organization or issuer shall not be liable for the disclosure or any subsequent use or misuse of the data. The health insurance organization or issuer shall be entitled to claim any statutory privileges against disclosure that the provider who furnished the information to the health issuer is entitled to claim.
(b) A person who, in good faith and without malice, takes an action or makes a decision or recommendation, or who furnishes any records, information, or assistance to a quality committee as a member, agent, or employee of a health insurance organization or issuer's quality committee in furtherance of the quality assessment or quality improvement activities of the health insurance organization or issuer, shall not be subject to liability for civil damages or any legal action in consequence of his/her action, nor shall the health insurance organization or issuer or any of its officers, directors, employees, or agents be liable for the activities of such person. This section shall not be construed to relieve any person of liability arising from treatment of a patient.
(c)
(1) The information considered by a quality committee and the records of its meetings shall be confidential and not subject to subpoena or order to produce, except in hearings held by the Commissioner. No member of a quality committee, or staff engaged in assisting or engaged in the quality assessment or quality improvement activities may be subpoenaed to testify in any judicial or quasi-judicial proceeding if the subpoena is based solely on these activities.
(d) To fulfill its obligations under this section, the health insurance organization or issuer shall have access to treatment records and other information pertaining to the diagnosis, treatment or health status of any covered person or enrollee.
History —Aug. 29, 2011, No. 194, added as § 20.090 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-118/9360/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360)›§ 9360 - Contracting
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 118 - Health Insurance Organization or Issuer Quality Assessment and Improvement (§§ 9351 — 9360) › § 9360 - Contracting
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Whenever a health insurance organization or issuer contracts to have another entity perform the quality assessment or quality improvement functions, the Commissioner shall hold the health insurance organization or issuer responsible for monitoring the activities of the entity with which it contracts.
History —Aug. 29, 2011, No. 194, added as § 20.100 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-120/9391/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400)›§ 9391 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9391 - Title
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This chapter shall be known and may be cited as the Health Insurance Organizations or Issuers Grievance Procedure. In the case of plans for private employers governed by the Employee Retirement Income Security Act of 1974, known as ERISA, any provision in this chapter found to be inconsistent with any federal law or regulation applicable to Puerto Rico regarding adverse determinations shall be understood to be amended to adjust to such law or regulation.
History —Aug. 29, 2011, No. 194, § 22.010, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 24, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-120/9392/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400)›§ 9392 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9392 - Purpose
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The purpose of this chapter is to provide standards for the establishment and maintenance of procedures by health insurance organizations and issuers to ensure that covered persons or enrollees have the opportunity for the appropriate resolution of grievances, as defined in this chapter.
History —Aug. 29, 2011, No. 194, § 22.020, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-120/9393/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400)›§ 9393 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9393 - Definitions
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For purposes of this chapter:
(a) Covered benefits or benefits.— Means those healthcare services to which a covered person or enrollee is entitled under the terms of a health plan.
(b) Certification.— Means a document that contains a determination by a health insurance organization or issuer, or a utilization review organization, that a request for a benefit under a health plan has been reviewed and, based on the information provided, satisfies the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care and effectiveness.
(c) Clinical review criteria.— Means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the health insurance organization or issuer to determine the medical necessity and appropriateness of healthcare services.
(d) Adverse determination.— Means:
(1) A determination by a health insurance organization or issuer, or a utilization review organization that, based upon the information provided, a request for a benefit under a health plan, upon application of any utilization review technique, does not meet the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care or effectiveness, or is determined to be experimental or investigational, and the requested benefit is therefore denied, reduced, or terminated, or payment is not provided or made, in whole or in part, for such benefit.
(2) the denial, reduction, termination, or failure to make payment, in whole or in part, for a benefit based on a determination by a health insurance organization or issuer, or a utilization review organization, of a covered person or enrollee's eligibility to participate in the health plan, or
(3) any prospective review or retrospective review determination that denies, reduces, or terminates, or fails to make payment, in whole or in part, for a benefit.
(e) Stabilized.— Means, with respect to an emergency medical condition, that no deterioration of the condition of the patient is likely, within reasonable medical probability, before the transfer of such individual from a facility.
(f) Clinical peer.— Means a physician or other healthcare professional who holds a non-restricted license in a state of the United States or in Puerto Rico, and in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review.
(g) Case management.— Means a coordinated set of activities established by a health insurance organization or issuer and conducted for individual patient management of serious, complicated, protracted, or other health conditions.
(h) Managed care clan.— Means:
(1) A health plan that requires a covered person or enrollee to use, or creates incentives, including financial incentives, for a covered person or enrollee to use healthcare providers managed, owned, under contract with, or employed by the health insurance organization or issuer.
(2) A managed care plan.— Includes:
(a) A preferred network plan, as defined in § 9002 of this title, and
(b) an open-ended plan, as defined in § 9002 of this title.
(i) Utilization review organization.— Means an entity contracted by a health insurance organization or issuer to conduct utilization review when such health insurance organization or issuer does not perform utilization review for its own health plan. It shall not be construed as a requirement for health insurance organizations or issuers to subcontract an independent entity to carry out utilization review processes.
(j) Health plan.— Means an insurance policy, contract, certificate, or agreement issued by a health insurance organization, healthcare service organization, or any other issuer, in exchange for the payment of premiums or on a prepaid basis, through which such health insurance organization, healthcare organization, or other issuer provides or pay for certain medical, hospital, major medical, dental, mental health, or incidental services.
(k) Discharge planning.— Means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility.
(l) Grievance.— Means a written complaint or an oral complaint if the complaint involves an urgent care request, submitted by or on behalf of a covered person or enrollee regarding:
(1) Availability, delivery, or quality of healthcare services, including complaints regarding an adverse determination made pursuant to utilization review;
(2) claims payment, handling, or reimbursement for healthcare services, or
(3) matters pertaining to the contractual relationship between a covered person or enrollee and a health insurance organization or issuer.
(m) Network.— Means the group of participating providers providing services to a managed care plan.
(n) Concurrent review.— Means utilization review conducted during a patient's stay or course of treatment in a facility, the office of a healthcare professional, or other inpatient or outpatient healthcare setting.
(o) Ambulatory review.— Means utilization review of healthcare services performed or provided in an outpatient setting.
(p) Utilization review.— Means a set of formal techniques designed to monitor healthcare services, procedures, or facilities or to evaluate the medical necessity, appropriateness, efficacy, or efficiency thereof. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review.
(q) Prospective review.— Means utilization review conducted prior to the provision of a healthcare service or a course of treatment, in accordance with a health insurance organization or issuer's requirement that such healthcare service or course of treatment, in whole or in part, be approved prior to its provision.
(r) Retrospective review.— Means any review of a request for a benefit that is not a prospective review request. “Retrospective review” does not include the review of a claim that is limited to veracity of documentation or accuracy of coding.
(s) Second opinion.— Means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed healthcare service to assess the medical necessity and appropriateness of such initial proposed healthcare service.
(t) Urgent care request.— Means:
(1) A request for a healthcare service or course of treatment with respect to which the time period for making a non-urgent care request determination:
(A) Could seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, or
(B) in the opinion of an attending healthcare professional with knowledge of the covered person or enrollee's medical condition, would subject said covered person or enrollee to severe pain that cannot be adequately managed without the healthcare service or treatment that is the subject of the request.
(2) In determining whether a request is to be treated as an urgent care request, an individual acting on behalf of the health insurance organization or issuer shall apply the judgment of a prudent layperson that possesses an average knowledge of health and medicine. Any request that an attending healthcare professional with knowledge of the covered person or enrollee's medical condition determines is an urgent care request within the meaning of clause (1) of this subsection shall be treated as an urgent care request.
History —Aug. 29, 2011, No. 194, § 22.030, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-120/9394/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400)›§ 9394 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9394 - Applicability and scope
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Except as otherwise specified, this chapter shall apply to all health insurance organizations or issuers.
None of the provisions of this chapter shall limit or in any way impair the legal powers of the Office of the Patient’s Advocate, the Medical Discipline and Licensure Board, or the Puerto Rico Health Insurance Administration to initiate, investigate, process, or adjudicate new or pending grievances. None of the provisions of this chapter shall be construed as an amendment or repeal of the laws, regulations, or procedures of the Office of the Patient’s Advocate, the Medical Discipline and Licensure Board, or the Puerto Rico Health Insurance Administration.
History —Aug. 29, 2011, No. 194, § 22.040, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 25, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-120/9395/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400)›§ 9395 - Requirements to report grievances to the Commissioner
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9395 - Requirements to report grievances to the Commissioner
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(a) Health insurance organizations or issuers shall maintain written records to document all grievances received during a calendar year (the register).
(b) A request for a first level review of a grievance involving an adverse determination shall be processed in compliance with § 9397 of this title. A request for a standard review of a grievance not involving an adverse determination shall be processed in compliance with § 9398 of this title.
(c) A request for an additional voluntary review of a grievance shall be processed in compliance with § 9399 of this title.
(d) For each grievance, the register shall contain at least the following information:
(1) A general description of the reason(s) for the grievance;
(2) the date received;
(3) the date of each review or, if applicable, review meeting;
(4) decision/resolution at each level of the grievance, if applicable;
(5) date of decision/resolution at each level, if applicable, and
(6) name of the covered person or enrollee for whom the grievance was filed.
(e) The register shall be maintained in a manner that is clear and accessible to the Commissioner.
(f)
(1) Health insurance organizations or issuers shall retain the register compiled for a calendar year for the longer of five (5) years or until the Commissioner has issued a final report of an examination that contains a review of the register for that calendar year.
(2)
(A) Health insurance organizations or issuers shall submit to the Commissioner, at least annually, a report in the format specified by him/her.
(B) The report shall include the following for each type of health plan offered by the health insurance organization or issuer:
(i) The certificate of compliance required by § 9396(c) of this title;
(ii) the number of covered persons or enrollees;
(iii) the total number of grievances;
(iv) the number of grievances for which a covered person or enrollee requested an additional voluntary grievance review pursuant to § 9399 of this title;
(v) the number of grievances resolved at each level, if applicable, and their decision/resolution;
(vi) the number of grievances appealed to the Commissioner of which the health insurance organization or issuer has been informed;
(vii) the number of grievances referred to alternative dispute resolution procedures, such as mediation or arbitration, or resulting in litigation, and
(viii) a synopsis of actions taken to correct the problems identified.
History —Aug. 29, 2011, No. 194, § 22.050, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-120/9396/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400)›§ 9396 - Grievance review procedures
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9396 - Grievance review procedures
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(a) Except as specified in § 9400 of this title, health insurance organizations or issuers shall receive and resolve grievances from covered persons or enrollees as provided in §§ 9397–9399 of this title.
(b) Health insurance organizations or issuers shall file a copy with the Commissioner of the procedures required under subsection (a) of this section, including all forms used to process the requests made. Any subsequent modifications to such procedures shall also be filed. The Commissioner may disapprove a filing received if it fails to comply with this chapter or the applicable regulations.
(c) In addition to the provisions of subsection (b) of this section, health insurance organizations or issuers shall file annually with the Commissioner, as part of the annual report required by § 9395 of this title, a certificate of compliance stating that such health insurance organizations or issuers have established and maintain, for each of their health plans, grievance procedures that fully comply with the provisions of this chapter.
(d) A description of the grievance procedures required under this section shall be included in the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage provided to covered persons or enrollees.
(e) The grievance procedure documents shall include a statement of a covered person or enrollee’s right to contact the Office of the Insurance Commissioner or the Office of the Patient’s Advocate for assistance at any time. The statement shall include the telephone number and address of the Office of the Insurance Commissioner and the Office of the Patient’s Advocate.
History —Aug. 29, 2011, No. 194, § 22.060, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 26, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-120/9397/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400)›§ 9397 - First level reviews of grievances involving an adverse determination
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9397 - First level reviews of grievances involving an adverse determination
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(a) Within one hundred eighty (180) days after the receipt of a notice of an adverse determination, a covered person or enrollee, or his/her authorized representative, may file a grievance with the health insurance organization or issuer requesting a first level review of the adverse determination.
(b) The health insurance organization or issuer shall provide the covered person or enrollee with the name, address, and telephone number of a person or organization designated to coordinate the first level review on behalf of the health insurance organization or issuer.
(c)
(1)
(A) If the grievance arises from an adverse determination involving utilization review, the health insurance organization or issuer shall designate one or more clinical peers of the same or similar specialty as would typically manage the case being reviewed to review the adverse determination. The designated clinical peer(s) shall not have been involved in the initial adverse determination.
(B) The health insurance organization or issuer shall ensure that, if more than one clinical peer is involved in the review, they have appropriate expertise.
(2) In conducting a review under this section, the reviewer(s) shall take into consideration all comments, documents, records, and other information regarding the request for services submitted by the covered person or enrollee, or his/her authorized representative, without regard to whether the information was submitted or considered in making the initial adverse determination.
(d)
(1)
(A) The covered person or enrollee or, if applicable, his/her representative shall be entitled to:
(i) Submit written comments, documents, records, and other material related to the grievance under review, and
(ii) receive from the health insurance organization or issuer, upon request and free of charge, access to and copies of all documents, records, and other information relevant to the grievance.
(B) For purposes of paragraph (A)(ii) of this clause, a document, record, or other information shall be considered relevant to a grievance if the document, record, or other information:
(i) Was relied upon in making the benefit determination;
(ii) was submitted, considered, or generated in the course of making the adverse determination, without regard to whether the document, record, or other information was relied upon in making the benefit determination;
(iii) demonstrates that, in making the benefit determination, the health insurance organization or issuer consistently applied the same administrative procedures and safeguards with respect to the covered person or enrollee as other similarly situated covered persons or enrollees, or
(iv) constitutes a statement of policy or guidance with respect to the health plan concerning the denied healthcare service or treatment for the covered person or enrollee's diagnosis, without regard to whether the statement or guidance was relied upon in making the initial adverse determination.
(2) The health insurance organization or issuer shall make the provisions of clause (1) of this subsection known to the covered person or enrollees or, if applicable, his/her authorized representative, within three (3) working days after the date of receipt of the grievance.
(e) For purposes of calculating the time periods within which a determination is required to be made and notice provided under subsection (f) of this section, the time period shall begin on the date the grievance is filed with the health insurance organization or issuer, without regard to whether all of the information necessary to make the determination accompanies such filing. If the health insurance organization or issuer understands that the grievance does not include all the necessary information to make a determination, it shall clearly indicate the covered person or enrollee or, if applicable, his/her authorized representative, the reasons for which it cannot process such grievance and the additional documents or information that the covered person or enrollee must provide.
(f)
(1) Health insurance organizations or issuers shall notify and issue a decision in writing, or electronically if the covered person or enrollee or, if applicable, his/her authorized representative, has agreed to be thus notified, within the timeframes provided in clause (2) or (3) of this subsection.
(2) With respect to a grievance requesting a first level review of an adverse determination involving a prospective review request, the health insurance organization or issuer shall notify and issue a decision within a reasonable period of time that is appropriate given the covered person or enrollee's medical condition, but not later than fifteen (15) calendar days after the receipt of the grievance.
(3) With respect to a grievance requesting a first level review of an adverse determination involving a retrospective review request, the health insurance organization or issuer shall notify and issue a decision within a reasonable period of time, but not later than thirty (30) calendar days after the receipt of the grievance.
(g) The determination issued pursuant to subsection (f) shall state in a manner that is comprehensible to the covered person or enrollee or, if applicable, his/her authorized representative:
(1) The titles and qualifying credentials of the person or persons participating in the first level review process (the reviewers).
(2) A statement of the reviewers' understanding of the covered person or enrollee's grievance.
(3) The reviewers' decision in clear terms and the contract basis or medical rationale for the covered person or enrollee or, if applicable, his/her authorized representative, to respond to the health insurance organization or issuer's position.
(4) The evidence or documentation used as the basis for the decision.
(5) In the event that the health insurance organization or issuer's first level review decision results in an adverse determination, the following shall also be included:
(A) The specific reasons for the adverse determination;
(B) the reference to the specific health plan provisions on which the determination is based;
(C) a statement that the covered person or enrollee is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant, as the term “relevant” is defined in subsection (d)(1)(B) of this section;
(D) if the health insurance organization or issuer relied upon an internal rule, guideline, protocol, or other similar criterion to make the final adverse determination, a copy of such rule, guideline, protocol, or other similar criterion in which the final adverse determination was based shall be provided, upon request and free of charge, to the covered person or enrollee or, if applicable, his/her authorized representative;
(E) if the final adverse determination is based on a medical necessity, experimental or investigational treatment, or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination or a statement that an explanation shall be provided, upon request and free of charge, to the covered person or enrollee or, if applicable, his/her authorized representative, and
(F) if applicable, instructions for requesting:
(i) A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the final adverse determination, as provided in paragraph (D) of this clause, and
(ii) a written statement of the scientific or clinical rationale for the determination, as provided in paragraph (E) of this clause.
(6) If applicable, a statement indicating:
(A) A description of the process to obtain an additional voluntary review if the covered person or enrollee wishes to request a voluntary review pursuant to § 9399 of this title;
(B) the written procedures governing the voluntary review, including any required timeframe for the review;
(C) a description of the procedures for obtaining an independent external review, pursuant to this Code's chapter on Health Insurance Organization or Issuer External Review, if the covered person or enrollee decides not to file for an additional voluntary review, and
(D) the covered person or enrollee's right to bring a civil action in a court of competent jurisdiction;
(7) If applicable, and stressing its voluntary nature, the following statement: “You and your health plan may have other voluntary alternative dispute resolution options, such as mediation or arbitration. One way to find out what may be available is to contact the Commissioner of Insurance”.
(8) Notice of the covered person or enrollee’s right to contact the Office of the Insurance Commissioner and the Office of the Patient’s Advocate for assistance with respect to any claim, grievance or appeal at any time, including the telephone number and address of the Office of the Insurance Commissioner and the Office of the Patient’s Advocate.
History —Aug. 29, 2011, No. 194, § 22.070, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 27, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-120/9398/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400)›§ 9398 - Standard reviews of grievances not involving an adverse determination
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9398 - Standard reviews of grievances not involving an adverse determination
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(a) Health insurance organizations or issuers shall establish written procedures for standard reviews of grievances that do not involve an adverse determination.
(b)
(1) The procedures shall permit a covered person or enrollee, or his/her authorized representative, to file a grievance that does not involve an adverse determination with the health insurance organization or issuer under this section.
(2)
(A) A covered person or enrollee, or his/her authorized representative, shall be entitled to submit written material for the persons designated by the health insurance organization or issuer to consider when conducting the standard review.
(B) The health insurance organization or issuer shall notify the covered person or enrollee or, if applicable, his/her authorized representative, of such covered person or enrollee's rights pursuant to paragraph (A) of this clause within three (3) business days after receiving the grievance.
(c)
(1) Upon receipt of the grievance, a health insurance organization or issuer shall designate one or more persons to conduct the standard review.
(2) To conduct the standard review of the grievance, the health insurance organization or issuer shall not designate the same person that handled the matter that is the subject of such grievance.
(3) The health insurance organization or issuer shall provide the covered person or enrollee or, if applicable, his/her authorized representative, with the name, address, and telephone number of the persons designated to conduct the standard review.
(d) The health insurance organization or issuer shall provide written notification of the decision to the covered person or enrollee or, if applicable, his/her authorized representative, within thirty (30) calendar days after the receipt of the grievance.
(e) The written decision issued pursuant to subsection (d) shall contain:
(1) The titles and qualifying credentials of the persons participating in the standard review process (the reviewers).
(2) A statement of the reviewers' understanding of the grievance.
(3) The reviewers' decision in clear terms and the contract basis or medical rationale for the covered person or enrollee to respond to the health insurance organization or issuer's position.
(4) A reference to the evidence or documentation used as the basis for the decision.
(5) If applicable, a written statement including:
(A) A description of the process to obtain an additional voluntary review if the covered person or enrollee wishes to request a voluntary review pursuant to § 9399 of this title, and
(B) the written procedures governing the voluntary review, including any required timeframe for the review.
(6) Notice of the covered person or enrollee’s right to contact the Office of the Insurance Commissioner and the Office of the Patient’s Advocate for assistance with respect to any claim, grievance or appeal at any time, including the telephone number and address of the Office of the Insurance Commissioner and the Office of the Patient’s Advocate.
History —Aug. 29, 2011, No. 194, § 22.080, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 28, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-120/9399/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400)›§ 9399 - Voluntary level of reviews of grievances
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9399 - Voluntary level of reviews of grievances
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(a)
(1) A health insurance organization or issuer that offers managed care plans shall establish a voluntary review process for its managed care plans to give those covered persons or enrollees who are dissatisfied with the first level review decision made pursuant to § 9397 of this title, or who are dissatisfied with the standard review decision made pursuant to § 9398 of this title, the option to request an additional voluntary review, at which they shall be entitled to appear before the designated representatives of the health insurance organization or issuer.
(2) This section shall not apply to health indemnity plans.
(b)
(1) A health insurance organization or issuer required by this section to establish a voluntary review process shall provide covered persons or enrollees, or their authorized representatives, with a notice pursuant to § 9397(g)(6) or § 9398(e)(5) of this title, as appropriate. Such notice shall indicate the option to file a request for an additional voluntary review.
(2) Upon receipt of a request for an additional voluntary review, the health insurance organization or issuer shall send notice to the covered person or enrollee or, if applicable, his/her authorized representative, of the covered person or enrollee's right to:
(A) Request, within the timeframe specified in clause (3)(A) of this subsection, the opportunity to appear in person before a review panel of the health insurance organization or issuer's designated representatives;
(B) receive from the health insurance organization or issuer, upon request, copies of all documents, records, and other information that is not confidential or privileged, related to the covered person or enrollee's request for an additional voluntary review;
(C) present the covered person or enrollee's case to the review panel;
(D) submit written comments, documents, records, and other material related to the request for an additional voluntary review for the review panel to consider both before and during the review meeting, if applicable;
(E) if applicable, ask questions to any representative of the health insurance organization or issuer on the review panel, and
(F) be assisted or represented by an individual of the covered person or enrollee's choice, including an attorney.
(3)
(A) A covered person or enrollee, or his/her authorized representative, who wishes to appear in person before the review panel shall make a written request to the health insurance organization or issuer not later than fifteen (15) business days after the receipt of the notice sent in accordance with clause (2) of this subsection.
(B) The covered person or enrollee's right to a fair review shall not be made conditional on such covered person or enrollee's appearance at the review.
(c)
(1)
(A) With respect to a request for voluntary review of a decision made pursuant to § 9397 of this title, a health insurance organization or issuer shall appoint a review panel to review the request.
(B) In conducting the review, the review panel shall take into consideration all comments, documents, records, and other information regarding the request for an additional voluntary review submitted by the covered person enrollee, or his/her authorized representative, without regard to whether the information was submitted or considered in making the first level review decision.
(C) The panel shall have the legal authority to bind the health insurance organization or issuer to the panel's decision. If, after twenty (20) calendars days, the health insurance organization or issuer fails to comply with the decision of the review panel, the latter shall notify such fact to the Commissioner.
(2)
(A) Except as provided in paragraph (B) of this clause, a majority of the panel shall be comprised of individuals who were not involved in the first level review decision made pursuant to § 9397 of this title.
(B) An individual who was involved in the first level review decision may be a member of the panel or appear before the same to present information or answer questions.
(C) The health insurance organization or issuer shall ensure that the individuals conducting the additional voluntary review are healthcare professionals with the appropriate expertise.
(D) The individuals conducting the additional voluntary review shall not:
(i) Be a provider in the covered person or enrollee's health plan, or
(ii) have a financial interest in the outcome of the review.
(d)
(1)
(A) With respect to a request for an additional voluntary review of a decision made pursuant to § 9398 of this title, a health insurance organization or issuer shall appoint a review panel to review the request.
(B) The panel shall have the legal authority to bind the health insurance organization or issuer to the panel's decision. If, after twenty (20) calendars days, the health insurance organization or issuer fails to comply with the decision of the review panel, the latter shall notify such fact to the Commissioner.
(2)
(A) Except as provided in paragraph (B) of this clause, a majority of the panel shall be comprised of employees or representatives of the health insurance organization or issuer who were not involved in the standard review conducted pursuant to § 9398 of this title.
(B) An employee or representative of the health insurance organization or issuer who participated in the standard review may be a member of the panel or appear before the same to present information or answer questions.
(e)
(1)
(A) Whenever a covered person or enrollee, or his/her authorized representative, requests, within the timeframe specified in subsection (c) or (d) of this section, to appear in person before the review panel, the procedures for conducting the additional voluntary review shall be governed by the provisions described hereinbelow.
(B)
(i) The review panel shall schedule and hold a review meeting not later than thirty (30) calendar days after the receipt of the request for an additional voluntary review.
(ii) The covered person or enrollee or, if applicable, his/her authorized representative, shall be notified in writing, at least fifteen (15) business days in advance, of the date of the review meeting.
(iii) The health insurance organization or issuer shall not unreasonably deny a request for postponement of the review made by the covered person enrollee, or his/her authorized representative.
(C) The review meeting shall be held during regular business hours at a location reasonably accessible to the covered person or enrollee or, if applicable, his/her authorized representative.
(D) In cases where a face-to-face meeting is not practical for geographic reasons, a health insurance organization or issuer shall offer the covered person or enrollee or, if applicable, his/her authorized representative, the opportunity to communicate with the review panel, at the health insurance organization or issuer's expense, by conference call, video conferencing, or other appropriate technology.
(E) If the health insurance organization or issuer intends to have legal representation, such health insurance organization or issuer shall notify the covered person or enrollee or, if applicable, his/her authorized representative, at least fifteen (15) calendar days in advance of the date of the review meeting. It shall also notify the covered person or enrollee that he/she may obtain legal representation of his/her own.
(F) The review panel shall issue a written decision, as provided in subsection (f) of this section, to the covered person or enrollee or, if applicable, his/her authorized representative, not more than ten (10) business days of completing the review meeting.
(2) Whenever the covered person or enrollee or, if applicable, his/her authorized representative, does not request the opportunity to appear in person before the review panel, such panel shall issue a decision and notify it in writing or electronically (if it has been agreed to thus notify this decision) as provided in subsection (f) of this section, within forty-five (45) calendar days after the earlier of:
(A) The date on which the covered person or enrollee, or his/her authorized representative, notifies the health insurance organization or issuer of the decision not to appear in person before the review panel, or
(B) the date on which the covered person's or enrollee's, or his/her authorized representative's opportunity to request to appear in person before the review panel expires, pursuant to subsection (b)(3)(A) of this section.
(f) The written decision issued pursuant to subsection (e) shall contain:
(1) The titles and qualifying credentials of the members of the review panel.
(2) A statement of the review panel's understanding of the request for an additional voluntary review and all pertinent facts.
(3) The rationale for the review panel's decision.
(4) A reference to evidence or documentation considered by the review panel in making that decision.
(5) In cases concerning a request for an additional voluntary review involving an adverse determination:
(A) The instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination, and
(B) if applicable, a statement describing the procedures for obtaining an independent external review of the adverse determination pursuant to the chapter on Health Insurance Organization or Issuer External Review of this Code.
(6) Notice of the covered person or enrollee’s right to contact the Office of the Insurance Commissioner and the Office of the Patient’s Advocate for assistance with respect to any claim, grievance or appeal at any time, including the telephone number and address of the Office of the Insurance Commissioner and the Office of the Patient’s Advocate.
History —Aug. 29, 2011, No. 194, § 22.090, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 29, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-120/9400/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400)›§ 9400 - Expedited reviews of grievances involving an adverse determination
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9400 - Expedited reviews of grievances involving an adverse determination
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(a) Health insurance organizations or issuers shall establish written procedures for the expedited review of urgent care requests involving an adverse determination.
(b) The procedures shall allow a covered person or enrollee, or his/her authorized representative, to request an expedited review under this section to the health insurance organization or issuer either orally or in writing.
(c) A health insurance organization or issuer shall appoint an appropriate clinical peers in the same or similar specialty as would typically manage the case being reviewed to conduct the expedited review. Such clinical peers shall not have been involved in making the initial adverse determination.
(d) In an expedited review, all the necessary information, including the health insurance organization or issuer's decision, shall be transmitted between the health insurance organization or issuer and the covered person or enrollee or, if applicable, his/her authorized representative, by telephone, fax, or the most expeditious method available.
(e) An expedited review decision shall be made and the covered person or enrollee or, if applicable, his/her authorized representative, shall be notified of the decision in accordance with subsection (g) of this section as expeditiously as the covered person or enrollee's medical condition requires, but in no event in more than forty-eight (48) hours after the receipt of the request for the expedited review.
(f) For purposes of calculating the time periods within which a decision is required to be made and notified under subsection (e) of this section, the time period shall begin on the date the request for an expedited review is filed with the health insurance organization or issuer without regard to whether all of the information necessary to make the determination accompanies such filing.
(g)
(1) The notification of the decision shall describe the following, in a manner that is comprehensible to the covered person or enrollee or, if applicable, his/her authorized representative:
(A) The titles and qualifying credentials of the persons participating in the expedited review process (the reviewers);
(B) a statement of the reviewers' understanding of the covered person's request for an expedited review;
(C) the reviewers' decision in clear terms, and the contract basis or medical rationale for the covered person or enrollee to respond to the health insurance organization or issuer's position;
(D) a reference to the evidence or documentation used as the basis for the decision, and
(E) If the decision involves an adverse determination, the notice shall provide:
(i) The specific reasons for the final adverse determination.
(ii) Reference to the specific plan provisions on which the determination is based.
(iii) If the health insurance organization or issuer relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination, a copy of such specific rule, guideline, protocol or other similar criterion relied upon to make the adverse determination shall be provided, upon request and free of charge, to the covered person or enrollee.
(iv) If the final adverse determination is based on a medical necessity, experimental or investigational treatment, or similar exclusion or limit, an explanation of the scientific or clinical judgment for making the determination.
(v) If applicable, instructions for requesting:
(I) A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination in accordance with subparagraph (iii) of this paragraph, or
(II) a written statement of the scientific or clinical rationale for the adverse determination in accordance with subparagraph (iv) of this paragraph.
(vi) A description of the procedures for obtaining an independent external review pursuant to the chapter on Health Insurance Organization or Issuer External Review of this Code.
(vii) A statement indicating the covered person's right to bring a civil action in a court of competent jurisdiction;
(viii) The following statement, stressing the voluntary nature of the procedures: “You and your health plan may have other voluntary alternative dispute resolution options, such as mediation or arbitration. One way to find out what may be available is to contact the Commissioner of Insurance”.
(ix) Notice of the covered person or enrollee’s right to contact the Office of the Insurance Commissioner and the Office of the Patient’s Advocate for assistance with respect to any claim, grievance or appeal at any time, including the telephone number and address of the Office of the Insurance Commissioner and the Office of the Patient’s Advocate.
(2)
(A) A health insurance organization or issuer shall provide the notice required under this section orally, in writing, or electronically.
(B) If notice of the adverse determination is provided orally, the health insurance organization or issuer shall provide written or electronic notice within three (3) days following the oral notification.
(3) None of these provisions shall be construed to limit the power of a health insurance organization or issuer to render an adverse determination ineffective without following the procedure set forth herein.
History —Aug. 29, 2011, No. 194, § 22.100, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 30, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9421/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9421 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9421 - Title
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This chapter shall be known and may be cited as the chapter on Utilization Review and Benefit Determination.
History —Aug. 29, 2011, No. 194, added as § 24.010 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9422/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9422 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9422 - Purpose
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This chapter establishes standards and criteria for the structure and operation of utilization review and benefit determination processes carried out by health insurance organizations or issuers. Its purpose is to facilitate ongoing assessment and management of healthcare services provided to covered persons or enrollees.
History —Aug. 29, 2011, No. 194, added as § 24.020 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9423/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9423 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9423 - Definitions
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For purposes of this chapter:
(a) Certification.— Means a document containing a determination by a health insurance organization or issuer or utilization review organization that a request for a benefit under the health insurance organization or issuer's health plan has been reviewed and, based on the information provided, satisfies the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care and effectiveness.
(b) Emergency medical condition.— Means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that would lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably expect that the absence of immediate medical attention would place an individual's health in serious jeopardy; or result in serious dysfunction of a bodily organ or part; or with respect to a pregnant woman who is having contractions, the lack of sufficient time to transfer her to other facilities before delivery, or that her transfer would result in serious jeopardy to her health or the health of her unborn child.
(c) Clinical review criteria.— Means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health insurance organization or issuer to determine the medical necessity and appropriateness of healthcare services.
(d) Adverse determination.— Means:
(1) A determination by a health insurance organization or issuer or utilization review organization that a requested benefit is denied, reduced or terminated or payment is not made, in whole or in part, for the benefit upon application of any utilization review technique, based upon the information provided, the requested benefit, according to the health plan does not meet the requirements for medical necessity, appropriateness, healthcare setting, level of care or effectiveness or is determined to be experimental or investigational;
(2) the denial, reduction, termination, or failure to make payment, in whole or in part, for a benefit based on a determination by a health insurance organization or issuer or utilization review organization of a covered person or enrollee's eligibility to participate in the health plan, or
(3) any prospective review or retrospective review determination that denies, reduces or terminates, or fails to make payment, in whole or in part, for a benefit.
(e) Stabilized.— Means, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from the transfer of the patient.
(f) Clinical peer.— Means a physician or other healthcare professional who holds a nonrestricted license in a state of the United States or in Puerto Rico and in the same or similar specialty as the physicians or healthcare professionals who typically manage the medical condition, procedure or treatment under review.
(g) Case management.— Means a coordinated set of activities established by the health insurance organization or issuer, conducted for individual patient management of serious, complicated, protracted, or other health conditions.
(h) Utilization review organization.— Means an entity contracted by a health insurance organization or issuer to conduct utilization review, other than a health insurance organization or issuer performing utilization review for its own health plans. It shall not be construed as a requirement for the health insurance organization or issuer to subcontract a utilization review organization to conduct its utilization review processes.
(i) Discharge planning.— Means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility.
(j) Concurrent review.— Means utilization review conducted during a patient's stay or course of treatment in a facility, the office of a healthcare professional or other inpatient or outpatient healthcare setting.
(k) Ambulatory review.— Means utilization review of healthcare services performed or provided in an outpatient setting.
(l) Utilization review.— Means a set of formal techniques designed to monitor healthcare services, procedures, or settings in which such services are provided, or to evaluate the medical necessity, appropriateness, efficacy, or efficiency thereof. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning or retrospective review.
(m) Prospective review.— Means utilization review conducted prior to the provision of a healthcare service or a course of treatment in accordance with a health insurance organization or issuer's requirement that the healthcare service or course of treatment, in whole or in part, be approved prior to its provision.
(n) Retrospective review.— Means any review of a request for a benefit that is carried out after the healthcare service is provided. Retrospective review does not include the review of a claim that is limited to veracity of documentation or accuracy of coding.
(o) Second opinion.— Means an opportunity or requirement to obtain a clinical evaluation by a provider, other than the one originally making a recommendation, for a proposed healthcare service to assess the medical necessity and appropriateness of such service.
(p) Emergency services.— Means healthcare services provided or required to treat an emergency medical condition.
(q) Urgent care request.— Means:
(1) A request for a healthcare service or course of treatment with respect to which the time periods for making a non-urgent care request determination:
(A) Could seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, or
(B) in the opinion of a physician with knowledge of the covered person or enrollee's medical condition, would subject the covered person or enrollee to severe pain that cannot be adequately managed without the healthcare service or treatment requested.
(2) In determining whether a request is be treated as an urgent care request, an individual acting on behalf of the health insurance organization or issuer shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine. Any request that a physician with knowledge of the covered person or enrollee's medical condition determines is an urgent care request within the meaning of clause (1) of this subsection shall be treated as an urgent care request by the health insurance organization or issuer.
History —Aug. 29, 2011, No. 194, added as § 24.030 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9424/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9424 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9424 - Applicability and scope
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This chapter shall apply to health insurance organizations or issuers offering a health plan that provides or performs utilization review services. The requirements of this chapter also shall apply to any designee of the health insurance organization or issuer or utilization review organization that performs utilization review functions on the health insurance organization or the issuer’s behalf.
History —Aug. 29, 2011, No. 194, added as § 24.040 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9425/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9425 - Corporate oversight of utilization review program
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9425 - Corporate oversight of utilization review program
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A health insurance organization or issuer shall be responsible for monitoring all utilization review activities carried out by, or on behalf of, the health insurance organization or issuer and for ensuring that all requirements of this chapter and the corresponding regulations are met. The health insurance organization or issuer also shall ensure that appropriate personnel have operational responsibility for the conduct of the health insurance organization or issuer's utilization review program.
History —Aug. 29, 2011, No. 194, added as § 24.050 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9426/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9426 - Contracting
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9426 - Contracting
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Whenever a health insurance organization or issuer contracts to have a utilization review organization or other entity perform the utilization review functions required by this chapter, the Commissioner shall hold the health insurance organization or issuer liable for monitoring the activities of the utilization review organization or entity with which a contract was executed. The health insurance organization or issuer shall ensure that the requirements of this chapter and corresponding regulations are met.
History —Aug. 29, 2011, No. 194, added as § 24.060 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9427/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9427 - Scope and content of utilization review program
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9427 - Scope and content of utilization review program
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(a)
(1) A health insurance organization or issuer that requires a request for benefits under the covered person or enrollee’s health plan to be subjected to utilization review shall implement a written utilization review program that describes all review activities and procedures, both delegated and non-delegated for:
(A) The procedure to file benefit requests;
(B) the notification of utilization review and benefit determinations, and
(C) the adverse determinations review process in accordance with §§ 9391–9400 of this title.
(2) The program document shall describe the following:
(A) Procedures to evaluate the medical necessity, appropriateness, efficacy or efficiency of healthcare services;
(B) data sources and clinical review criteria used in decision-making process;
(C) mechanisms to ensure consistent application of clinical review criteria and compatible decisions;
(D) data collection processes and analytical methods used in assessing utilization of healthcare services;
(E) provisions for assuring confidentiality of clinical and proprietary information;
(F) the organizational structure (e.g. utilization review committee, quality assurance or other committee) that periodically assesses utilization review activities and reports to the health insurance organization or issuer’s governing body, and
(G) the position of the staff functionally responsible for day- to-day program management.
(b)
(1) Health insurance organizations or issuers shall file with the Commissioner, in the prescribed format, an annual report summarizing the activities of the utilization review program.
(2)
(A) In addition to the annual report summarizing the activities of the utilization review program, health insurance organizations or issuers shall keep, for a period of not less than six (6) years, records of all requests for benefits and claims and notifications related to the utilization review process.
(B) Health insurance organizations or issuers shall make the records mentioned in paragraph (A) of this clause available upon request to the Commissioner and any other regulatory agency.
History —Aug. 29, 2011, No. 194, added as § 24.070 on Aug. 23, 2012, No. 203, § 5, eff. 90 days Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9428/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9428 - Operational requirements
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9428 - Operational requirements
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(a) A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health insurance organization or issuer may develop its own clinical review criteria or it may obtain or use license clinical review criteria from qualified vendors. A health insurance organization or issuer shall make its clinical review criteria available upon request to the Commissioner and other authorized government agencies.
(b) Qualified healthcare professionals shall administer the utilization review program and oversee utilization review decisions. One (1) or more clinical peers shall evaluate the clinical appropriateness of adverse determinations.
(c)
(1) A health insurance organization or issuer shall conduct utilization reviews and issue benefit determinations in a timely manner pursuant to the requirements of §§ 9429 and 9430 of this title.
(2)
(A) Whenever a health insurance organization or issuer fails to adhere to the requirements of § 9429 or 9430 of this title, the covered person or enrollee shall be deemed to have exhausted the provisions of this chapter and may take action under paragraph (B) of this clause, whether the health insurance organization or issuer alleges to have substantially met the requirements of § 9429 or 9430 of this title, or if it alleges a de minimus violation.
(B)
(i) In accordance with the provisions of paragraph (A) of this clause, a covered person or enrollee may file a request for external review in accordance with the procedures outlined §§ 9501–9517 of this title.
(ii) In addition to the external review process provided in subparagraph (i) above, a covered person or enrollee shall be entitled to pursue any available remedies under Commonwealth or federal law on the basis that the health insurance organization or issuer failed to provide a reasonable internal grievances process that would yield a decision on the merits of the claim.
(d) A health insurance organization or issuer shall have a process to ensure that utilization reviewers apply clinical review criteria in conducting utilization review consistently.
(e) A health insurance organization or issuer shall routinely assess the effectiveness and efficiency of its utilization review program.
(f) A health insurance organization or issuer's data systems shall be sufficient to support utilization review program activities and to generate management reports to enable the health insurance organization or issuer to monitor and manage healthcare services effectively.
(g) If a health insurance organization or issuer delegates any utilization review activities to a utilization review organization, the health insurance organization or issuer shall maintain adequate oversight, which shall include:
(1) A written description of the utilization review organization's activities and responsibilities, including reporting requirements;
(2) evidence of formal approval of the utilization review organization program by the health insurance organization or issuer, and
(3) a process by which the health insurance organization or issuer evaluates the performance of the utilization review organization.
(h) The health insurance organization or issuer shall coordinate the utilization review program with other medical management activity conducted by the issuer, such as quality assurance, credentialing, provider contracting, data reporting, grievance procedures, processes for assessing covered person or enrollee's satisfaction and risk management.
(i) A health insurance organization or issuer shall provide covered persons or enrollees and participating providers with adequate mechanisms to clear up any doubts or questions related to the review and benefit determination program.
(j) When conducting utilization review, the health insurance organization or issuer shall collect only the information necessary, including pertinent clinical information, to make the utilization review.
(k)
(1) The health insurance organization or issuer shall ensure that the utilization review process is conducted in a manner to ensure the independence and impartiality of the individuals involved in making the utilization review or benefit determination.
(2) In ensuring the independence and impartially of individuals involved in making the utilization review or benefit determination, the health insurance organization or issuer shall not make decisions regarding hiring, compensation, termination, promotion or other similar matters with respect to such individuals based upon the likelihood that the individual will support the denial of benefits.
History —Aug. 29, 2011, No. 194, added as § 24.080 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9429/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9429 - Procedures for standard utilization review and benefit determinations
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9429 - Procedures for standard utilization review and benefit determinations
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(a) A health insurance organization or issuer shall maintain written procedures for making standard utilization review and benefit determinations on requests for benefits submitted by covered persons or enrollees and for notifying its determinations within the specified time frames required under this section.
(b)
(1)
(A)
(i) For prospective review determinations, a health insurance organization or issuer shall make the determination and notify the covered person or enrollee of the determination, whether the issuer certifies the provision of the benefit or not, within a reasonable period of time appropriate to the covered person or enrollee's medical condition, but in no event later than fifteen (15) days after the date the health issuer receives the request.
(ii) Whenever the determination is an adverse determination, the health insurance organization or issuer shall make the notification of the adverse determination in accordance with subsection (f) of this section.
(B) The time period for making a determination and notifying the covered person or enrollee of the determination may be extended one time by the health insurance organization or issuer for up to fifteen (15) days, provided the health insurance organization or issuer meets the following requirements:
(i) Determines that an extension is necessary due to matters beyond the health insurance organization or issuer's control, and
(ii) notifies the covered person or enrollee prior to the expiration of the initial fifteen (15)-day time period, of the circumstances requiring the extension of time and the date by which the determination is expected to be made.
(C) If the extension is necessary due to the failure of the covered person or enrollee to submit information necessary for the health insurance organization or issuer to reach a determination on the request, the notice of extension shall meet the following requirements:
(i) Specifically describe the required information necessary to complete the request, and
(ii) give the covered person or enrollee at least forty- five (45) days from the date of receipt of the notice to provide the specified information.
(2)
(A) Whenever the health insurance organization or issuer receives a prospective review request that fails to meet the health insurance organization or issuer's procedure to file requests for benefits, it shall notify the covered person or enrollee of such failure and provide in the notice information on the proper procedures to be followed for filing a request.
(B)
(i) The notice of the failure shall be provided, as soon as possible, but in no event later than five (5) days following the date of the failure.
(ii) The health insurance organization or issuer may provide the notice orally or, if so requested by the covered person or enrollee, in writing.
(C)
(1) For concurrent review determinations, if a health insurance organization or issuer has previously certified an ongoing course of treatment to be provided over a period of time or number of treatments, the following rules shall apply:
(A) Any reduction or termination by the health insurance organization or issuer during the course of treatment before the end of the previously certified period or number of treatments, other than by health plan amendment or termination of the health plan, shall constitute an adverse determination, and
(B) The health insurance organization or issuer shall notify the covered person or enrollee of the adverse determination in accordance with subsection (f) of this section in advance of the reduction or termination to allow the covered person or enrollee to file a grievance pursuant to §§ 9391–9400 of this title and obtain a determination with respect to such grievance before the benefit is reduced or terminated.
(2) The healthcare service or treatment that is the subject of the adverse determination shall be continued until the health insurance organization or issuer notify the covered person or enrollee of the determination made with respect to a grievance filed pursuant to §§ 9391–9400 of this title.
(d)
(1)
(A) For retrospective review determinations, a health insurance organization or issuer shall make the determination within a reasonable period of time, but in no event later than thirty (30) days after the date of receiving the request.
(B) If the determination is an adverse determination, the health insurance organization or issuer shall provide notice of the adverse determination in accordance with subsection (f) of this section.
(2)
(A) The time period for making a determination and notifying the covered person or enrollee may be extended one time by the health insurance organization or issuer for up to fifteen (15) days, provided the health insurance organization or issuer meets the following requirements:
(i) Determines that an extension is necessary due to matters beyond the health insurance organization or issuer's control, and
(ii) notifies the covered person or enrollee prior to the expiration of the initial thirty (30)-day time period, of the circumstances requiring the extension of time and the date by which a determination is expected to be made.
(B) If the extension is necessary due to the failure of the covered person or enrollee to submit information necessary for the health insurance organization or issuer to reach a determination on the request, the notice of extension shall:
(i) Specifically describe the required information necessary to complete the request, and
(ii) give the covered person or enrollee at least forty- five (45) days from the date of receipt of the notice for the covered person or enrollee to provide the specified additional information.
(e)
(1) For purposes of calculating the time period within which the health insurance organization or issuer is required to make a determination under subsections (b) and (d) of this section, the time period shall begin on the date the request is filed with the health insurance organization or issuer in accordance with the procedures established pursuant to § 9427 of this title without regard to whether all of the information necessary to make the determination accompanies the filing.
(2)
(A) If the time period for making the determination is extended due to the covered person or enrollee's failure to submit the information necessary to make the determination, the time period for making the determination shall be tolled from the date on which the health insurance organization or issuer sends the notification of the extension to the covered person or enrollee or until the earlier of:
(i) The date on which the covered person or enrollee responds to the request for additional information, or
(ii) the date on which the specified information should have been submitted.
(B) If the covered person or enrollee fails to submit the information before the end of the period of the extension, the health insurance organization or issuer may deny the certification of the requested benefit.
(f)
(1) If as a result of a utilization review and benefit determination process, the health insurance organization or issuer provides a notification of an adverse determination such notification shall, in a manner calculated to be understood by the covered person or enrollee, set forth:
(A) Information sufficient to identify the benefit request or claim involved, including, if applicable, the date of service; the provider; the claim amount; the diagnosis code and its meaning; and the treatment code and its meaning;
(B) the specific reasons for the adverse determination, including the denial code and its meaning, as well as a description of the standard, if any, that was used in denying such benefit request or claim;
(C) reference to the specific plan provisions on which the determination is based;
(D) a description of any additional material or information necessary for the covered person or enrollee to perfect the benefit request, including an explanation of why the material or information is necessary to perfect the request;
(E) a description of the health insurance organization or issuer's grievance procedures established pursuant to §§ 9391–9400 of this title, including any time limits applicable to those procedures;
(F) if the health insurance organization or issuer relied upon an internal rule, guideline, protocol or other similar criterion to make the adverse determination, a copy of the rule, guideline, protocol or other similar criterion shall be provided free of charge to the covered person or enrollee;
(G) if the adverse determination is based on a medical necessity for the service or treatment or the experimental or investigational nature thereof or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination and for applying the terms of the health plan to the covered person or enrollee's medical circumstances shall be included with the notification, and
(H) a statement of the right of the covered person or enrollee, as appropriate, to contact the Office of the Commissioner or the Office of the Patient's Advocate at any time for assistance or, to file a civil suit in a court of competent jurisdiction upon completion of the health insurance organization or issuer's grievance procedure process. The statement shall include contact information for the Office of the Commissioner or the Office of the Patient's Advocate.
(2) A health insurance organization or issuer shall provide the notice required under this section in a culturally and linguistically appropriate manner as required under federal law.
History —Aug. 29, 2011, No. 194, added as § 24.090 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9430/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9430 - Procedures for expedited utilization review and benefit determinations
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9430 - Procedures for expedited utilization review and benefit determinations
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(a)
(1) Health insurance organizations or issuers shall establish written procedures for notifying covered persons or enrollees of expedited utilization review and benefit determinations with respect to urgent care requests.
(2)
(A) As part of the procedures required under clause (1) of this subsection, a health insurance organization or issuer shall provide that, if the covered person or enrollee fails to meet its filing procedures with regard to an urgent care request, the health insurance organization or issuer shall notify the covered person or enrollee of such failure and provide the proper procedures to be followed for filing a request.
(B) The notice of the failure in the filing of an urgent care request:
(i) Shall be provided to the covered person or enrollee, as soon as possible, but in no event later than twenty-four (24) hours after receipt of the request, and
(ii) may be provided orally or, if requested by the covered person or enrollee, in writing.
(b)
(1)
(A) For an urgent care request, the health insurance organization or issuer shall notify the covered person or enrollee of its determination with respect to the request, whether or not the determination is an adverse determination, as soon as possible, taking into account the medical condition of the covered person or enrollee, but in no event later than twenty-fours (24) hours after the date of the receipt of the request by the health insurance organization or issuer, unless the covered person or enrollee has failed to provide sufficient information for the health insurance organization or issuer to determine whether the benefits requested are covered benefits or payable under the health plan.
(B) In the case of an adverse determination, the health insurance organization or issuer shall provide notice of such adverse determination in accordance with subsection (e) of this section.
(2)
(A) If the covered person or enrollee has failed to provide sufficient information for the health insurance organization or issuer to make a determination, the health insurance organization or issuer shall provide notice of such failure to the covered person or enrollee, whether orally or, if requested by the covered person or enrollee, in writing, and shall indicate the specified information needed, as soon as possible, but in no event later than twenty-four (24) hours after the date of receipt of the request.
(B) The health insurance organization or issuer shall provide the covered person or enrollee a reasonable period of time to submit the additional necessary information, but in no event less than forty-eight (48) hours after the date notice of such failure was provided.
(C) The health insurance organization or issuer shall notify the covered person or enrollee its determination with respect to an urgent care request as soon as possible, but in no event less than forty-eight (48) hours after the earlier of the following:
(i) The health insurance organization or issuer's receipt of the requested specified additional information, or
(ii) the end of the period provided for the covered person or enrollee to submit the requested specified information.
(D) If the covered person or enrollee fails to submit the requested specified information before the end of the period granted, the health insurance organization or issuer may deny the certification of the requested benefit.
(E) In the case of an adverse determination, the health insurance organization or issuer shall provide notice of such adverse determination in accordance with subsection (e) of this section.
(c)
(1) For concurrent review urgent care requests, involving a request by the covered person or enrollee to extend the course of treatment beyond the initial period of time or the number of treatments prescribed, if the request is made at least twenty-four (24) hours prior to the expiration of the prescribed period of time or number of treatments, the health insurance organization or issuer shall make a determination with respect to the request and notify the covered person or enrollee of the determination, as soon as possible, taking into account the covered person or enrollee's medical condition but in no event more than twenty-four (24) hours after the date of the receipt of the request.
(d) For purposes of calculating the time periods within which the health insurance organization or issuer is required to make a determination under subsections (b) and (c) of this section, the time period shall begin on the date the request is filed with the health insurance organization or issuer in accordance with procedures established pursuant to § 9427 of this title for filing a request without regard to whether all of the information necessary to make the determination accompanies the filing.
(e)
(1) If as a result of a utilization review and benefit determination process the health insurance organization or issuer provides a notification of an adverse determination such notification shall, in a manner calculated to be understood by the covered person or enrollee, set forth:
(A) Information sufficient to identify the benefit request or claim involved, including, if applicable, the date of service; the provider; the claim amount; the diagnosis code and its meaning; and the treatment code and its meaning.
(B) The specific reasons for the adverse determination, including the denial code and its meaning, as well as a description of the standard, if any, that was used in denying such benefit request or claim.
(C) Reference to the specific plan provisions on which the determination is based.
(D) A description of any additional material or information necessary for the covered person or enrollee to perfect the benefit request, including an explanation of why the material or information is necessary to perfect the request.
(E) A description of the health insurance organization or issuer's grievance procedures established pursuant to §§ 9391–9400 of this title, including any time limits applicable to those procedures;
(F) A description of the health insurance organization or issuer's expedited review procedures established pursuant to § 9400 of this title, including any time limits applicable to those procedures.
(G) If the health insurance organization or issuer relied upon an internal rule, guideline, protocol or other similar criterion to make the adverse determination, a copy of the rule, guideline, protocol or other similar criterion shall be provided free of charge to the covered person or enrollee.
(H) If the adverse determination is based on a medical necessity for the service or treatment or the experimental or investigational nature thereof or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination and for applying the terms of the health plan to the covered person or enrollee's medical circumstances shall be included with the notification.
(I) A statement of the right of the covered person or enrollee, as appropriate, to contact the Office of the Commissioner or the Office of the Patient's Advocate at any time for assistance or, to file a civil suit in a court of competent jurisdiction upon completion of the health insurance organization or issuer's grievance procedure process. The statement shall include contact information for the Office of the Commissioner or the Office of the Patient's Advocate.
(2) A health insurance organization or issuer shall provide the notice required under this section in a culturally and linguistically appropriate manner as required under federal law.
History —Aug. 29, 2011, No. 194, added as § 24.100 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9431/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9431 - Emergency services
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9431 - Emergency services
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(a) When conducting utilization review or making a benefit determinations for emergency services, a health insurance organization or issuer shall comply with the provisions of this section.
(b) A health insurance organization or issuer shall cover emergency services necessary to screen and stabilize a covered person or enrollee in accordance with the following rules:
(1) A health insurance organization or issuer shall not require prior authorization for the emergency services described in subsection B above [sic], even if the emergency services are provided by a provider out of the health insurance organization or issuer's network (hereinafter, “non-participating provider”).
(2) If the emergency services are provided by a non-participating provider, no administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from participating providers shall be imposed.
(c)
(1) If the emergency services are provided by a participating provider, such services shall be subject to the applicable copayment, coinsurance, and deductible.
(2)
(A) If the emergency services are provided by a non- participating provider such services shall be subject to the same applicable copayment, coinsurance, and deductible, as if such services were provided by a participating provider.
(B) The covered person or enrollee shall not be required to pay any amount in excess of the applicable copayment, coinsurance and deductibles pursuant to the preceding paragraph.
(C) A health insurance organization or issuer meets the payment requirements of this section, if it provides payment of emergency services provided by a non-participating provider at a rate not less than the greater of the following:
(i) The rate negotiated with participating providers for emergency services, excluding any copayment or coinsurance imposed with respect to the covered person or enrollee.
(ii) The rate attributable to the emergency service provided, calculated using the same method the health insurance organization or issuer uses to determine payments for non-participating providers, but using the copayment, coinsurance and deductibles applicable to participating providers for the same services in lieu of the copayment, coinsurance and deductibles of non-participating providers.
(iii) The rate that would be paid under Medicare for the emergency services, excluding any copayment or coinsurance requirement applicable to participating providers.
(D)
(i) In the case of health plans with capitation or any other payment method that do not have a negotiated per-service rate for participating providers, the provisions of paragraph (C)(i) of this clause shall not apply.
(ii) If the health plan has more than one negotiated rate for a particular emergency service provided by participating providers, the amount referred to in paragraph (C)(i) of this clause is the median of such negotiated rates.
(3)
(A) Any cost-sharing requirement other than a copayment or coinsurance requirement, such as a deductible, may be imposed with respect to emergency services provided by non-participating providers to the extent such cost-sharing requirements generally apply to other services provided by non- participating providers.
(B) A deductible may be imposed with respect to emergency services provided by non-participating providers only as part of deductibles that generally apply to benefits or services provided by non-participating providers.
(d) To facilitate the review, for post-evaluation or post-stabilization services that a covered person or enrollee may require immediately, a health insurance organization or issuer shall provide access to a designated representative twenty-four (24) hours a day, seven (7) days a week.
History —Aug. 29, 2011, No. 194, added as § 24.110 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9432/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9432 - Confidentiality requirements
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9432 - Confidentiality requirements
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Health insurance organizations or issuers shall annually certify to the Commissioner that their utilization review programs comply with all applicable Commonwealth and federal law establishing health information confidentiality requirements.
History —Aug. 29, 2011, No. 194, added as § 24.120 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9433/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9433 - Disclosure requirements
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9433 - Disclosure requirements
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(a) A health insurance organization or issuer shall include a clear and comprehensive description of its utilization review and benefit determination procedures in the certificate of coverage or member handbook provided to covered persons or enrollees. The description shall include the procedures for obtaining review of adverse determinations, and a statement of rights and responsibilities of covered persons or enrollees with respect to those procedures.
(b) A health insurance organization or issuer shall include a summary of its utilization review and benefit determination procedures in materials intended for prospective covered persons or enrollees.
(c) A health insurance organization or issuer shall print on the health plan cards of the covered person or enrollee a toll-free telephone number to call for utilization review and benefit decisions.
History —Aug. 29, 2011, No. 194, added as § 24.130 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-122/9434/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434)›§ 9434 - Rulemaking authority
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9434 - Rulemaking authority
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The Commissioner may promulgate the necessary regulations to carryout the purposes of this chapter.
History —Aug. 29, 2011, No. 194, added as § 24.140 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9461/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9461 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9461 - Title
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This chapter shall be known and may be cited as the chapter on Managed Care Plan Network Adequacy.
History —Aug. 29, 2011, No. 194, added as § 26.010 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9462/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9462 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9462 - Purpose
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The purpose and intent of this chapter are to establish standards for the creation and maintenance of networks by health insurance organization or issuers and to assure the adequacy, accessibility and quality of healthcare services offered under a managed care plan. Requirements for contracts between health insurance organizations or issuers offering managed care plans and participating providers, particularly regarding the standards, terms, and provisions under which the participating provider will provide services to covered persons or enrollees are hereby established.
History —Aug. 29, 2011, No. 194, added as § 26.020 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9463/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9463 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9463 - Definitions
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For purposes of this chapter:
(a) Intermediary.— Means a person authorized to negotiate and execute contracts with health insurance organizations or issuers on behalf of healthcare providers or a healthcare provider network.
(b) Primary care provider.— Means a participating provider in charge of supervising, coordinating or providing initial care or continuing care to a covered person or enrollee. In addition, the primary care provider may be required by the health insurance organization or issuer to initiate a referral for specialty care and maintain supervision of healthcare services rendered to the covered person or enrollee.
(c) Network.— Means the group of participating providers providing services to a managed care plan.
History —Aug. 29, 2011, No. 194, added as § 26.030 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9464/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9464 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9464 - Applicability and scope
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This chapter shall apply to all health insurance organizations or issuers that offer managed care plans.
History —Aug. 29, 2011, No. 194, added as § 26.040 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9465/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9465 - Network adequacy
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9465 - Network adequacy
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(a) Any health insurance organization or issuer providing a managed care plan shall maintain a network that is sufficient in numbers and types of providers to assure that all services to covered persons or enrollees will be accessible without unreasonable delay.
(b) Covered persons or enrollees shall have access to emergency services twenty-four (24) hours per day, seven (7) days per week.
(c) Sufficiency shall be determined in accordance with the requirements of this section, and may be established by reference to any reasonable criteria used by the health insurance organization or the issuer, including but not limited to: provider-covered person or enrollee ratios by specialty; primary care provider-covered person or enrollee ratios; geographic accessibility; waiting times for appointments with participating providers; hours of operation; and the volume of technological and specialty services available to serve the needs of covered persons or enrollees requiring technologically advanced or specialty care.
(1) In any case where the health insurance organization or issuer has an insufficient number or type of participating provider to provide a covered benefit, such health insurance organization or issuer shall ensure that the covered person or enrollee obtains the covered benefit at the same cost to the covered person or enrollee than if the benefit were obtained from participating providers.
(2) The health insurance organization or issuer shall establish and maintain adequate arrangements to ensure reasonable proximity of participating providers to the business or personal residence of covered persons or enrollees. In determining whether a health insurance organization or issuer has complied with this provision, the Commissioner shall give due consideration to the relative availability of healthcare providers in the service area under consideration.
(3) A health insurance organization or issuer shall monitor the ability, clinical capacity, financial capability and legal authority of its providers to furnish all contracted benefits to covered persons or enrollees.
(d) Beginning on the effective date of this chapter, a health insurance organization or issuer shall file with the Commissioner an access plan meeting the requirements of this chapter for each of the managed care plans that the issuer offers in Puerto Rico. Any access plan of health insurance organizations or issuers shall be made available on its business premises and shall provide them to any interested party upon request. The health insurance organization or issuer shall devise an access plan prior to offering a new managed care plan and update the existing plan whenever it makes a material change to an existing managed care plan. The access plan shall describe or contain at least the following:
(1) The health insurance organization or issuer’s network;
(2) the health insurance organization or issuer’s procedures for making referrals within and outside its network;
(3) the health insurance organization or issuer’s process for monitoring and assuring the sufficiency of the network to meet the healthcare needs of populations that enroll in managed care plans;
(4) the health insurance organization or issuer’s efforts to address the needs of covered persons or enrollees who are illiterate or have diverse cultural and ethnic backgrounds, and physical and mental disabilities;
(5) the health insurance organization or issuer’s methods for assessing the healthcare needs of the covered persons or enrollees and their satisfaction with services;
(6) the health insurance organization or issuer’s method of informing covered persons or enrollees of the plan’s services and features, including but not limited to, the plan’s grievance procedures, its process for choosing and changing providers, and its procedures for providing and approving emergency and specialty care;
(7) the health insurance organization or issuer’s system for ensuring the coordination and continuity of care for covered persons or enrollees who are referred to specialty physicians, or use ancillary services, including social services and other community resources, and for ensuring appropriate discharge planning;
(8) the health insurance organization or issuer’s process for enabling covered persons or enrollees to change primary care providers;
(9) the health insurance organization or issuer’s proposed plan for providing continuity of healthcare services in the event of contract termination between the health insurance organization or issuer and any of its participating providers, or in the event of the health insurance organization or issuer’s insolvency or other inability to continue operations. The description shall be consistent with §§ 3041 et seq. of Title 24, known as the “Bill of Rights and Responsibilities of the Patient”, and explain how covered persons or enrollees will be notified of the contract termination, or the health insurance organization or issuer’s insolvency or other cessation of operations, as the case may be, and transferred to other providers in a timely manner, and
(10) any other information required by the Commissioner to determine compliance with the provisions of this chapter.
History —Aug. 29, 2011, No. 194, added as § 26.050 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9466/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9466 - Requirements for health insurance organizations or issuers and participating providers
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9466 - Requirements for health insurance organizations or issuers and participating providers
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A health insurance organization or issuer offering a managed care plan shall satisfy all the following requirements:
(a) A health insurance organization or issuer shall establish a mechanism whereby the participating provider will be notified on an ongoing basis of the specific covered health services for which the provider shall be responsible, including any limitations or conditions on services.
(b) Every contract between a health insurance organization or issuer and a participating provider shall set forth a hold harmless provision substantially similar to the following:
“In no event, including but not limited to nonpayment to providers, insolvency of the health insurance organization or issuer, or breach of this agreement, shall the provider bill, charge, or collect from a covered person or enrollee any amount for services provided pursuant to this agreement or have any recourse against a covered person or enrollee. Provided that this provision does not prohibit the provider from collecting coinsurance, deductibles or copayments, as specifically provided in the policy or evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to covered persons or enrollees. Except as provided herein, this agreement does not prohibit the provider from pursuing any available legal remedy.”
(c) Every contract between a health insurance organization or issuer and a participating provider shall set forth that in the event of a health insurance organization or issuer insolvency or other cessation of operations, covered services to covered persons or enrollees will continue to be offered through the period for which a premium has been paid to the health insurance organization or issuer on behalf of the covered person or enrollee or until the covered person or enrollee’s discharge from an inpatient facility, whichever time is greater. Covered benefits being offered to covered persons or enrollees confined in an inpatient facility on the date of insolvency or other cessation of operations of the health insurance organization or issuer shall continue until their continued confinement in an inpatient facility is no longer medically necessary.
(d) The contract provisions that satisfy the requirements of subsections (b) and (c) of this section shall be construed in favor of the covered person or enrollee, shall survive the termination of the contract between the health insurance organization or issuer and the provider regardless of the reason for termination, and shall supersede any oral or written contrary agreement between a provider and a covered person or enrollee.
(e) In no event shall a participating provider collect or attempt to collect from a covered person or enrollee any money owed to the provider by the health insurance organization or issuer.
(f)
(1) The health insurance organization or issuer’s selection standards shall be developed for primary care participating providers and each healthcare professional specialty. The standards shall be used by participating providers, their intermediaries, and any provider networks with which they contract in determining the selection of healthcare professionals. Selection criteria shall meet the requirements of §§ 9321–9328 of this title on Healthcare Professional Credentialing Verification and, furthermore, shall not be established in a manner:
(A) That would allow a health insurance organization or issuer to avoid high-risk populations by excluding providers because they are located in geographic areas that contain populations presenting a risk of higher than average claims, losses or health services utilization, or
(B) that would exclude providers because they treat or specialize in treating populations presenting a risk of higher than average claims, losses or health services utilization.
(2) The provisions of clause (1) of this subsection shall not be construed to prohibit a health insurance organization or issuer from declining to select a provider who fails to meet the other legitimate selection criteria of the health insurance organization or issuer developed in compliance with this chapter.
(3) The provisions of this chapter do not require a health insurance organization or issuer or the provider networks with which they contract, to employ specific providers or types of providers that meet their selection criteria, or to contract with more providers or types of providers than are necessary to maintain an adequate network.
(g) A health insurance organization or issuer shall make its selection criteria for participating providers available for review by the Commissioner.
(h) A health insurance organization or issuer shall notify participating providers of the providers’ responsibilities with respect to applicable administrative policies and programs, including but not limited to: payment terms, utilization review process, quality assessment and improvement programs, credentialing, grievance procedures, data reporting requirements, confidentiality requirements, and any applicable federal or Commonwealth programs.
(i) A health insurance organization or issuer shall not offer an inducement to a provider to provide less than medically necessary services to a covered person or enrollee.
(j) A health insurance organization or issuer shall not prohibit a participating provider from discussing other treatment options with covered persons or enrollees irrespective of the health insurance organization or issuer’s position on the treatment options, or from advocating on behalf of covered persons or enrollees within the utilization review or grievance processes established by the health insurance organization or issuer, provided that they have the authorization of the covered persons or enrollees.
(k) A health insurance organization or issuer shall require a provider to make medical records available for review or audit by the appropriate Commonwealth and federal authorities and to comply with the applicable Commonwealth and federal laws related to the confidentiality of medical or health records.
(l) The rights and responsibilities under a contract between a health insurance organization or issuer and a participating provider shall not be assigned or delegated by the provider without the prior written consent of the health insurance organization or issuer.
(m) A health insurance organization or issuer is responsible for ensuring that a participating provider furnishes covered benefits to all covered persons or enrollees without regard to the covered person or enrollee’s enrollment in the plan as a private purchaser of the plan or as a participant in a government financed program.
(n) A health insurance organization or issuer shall notify the participating providers of their obligations, if any, to collect applicable coinsurance, copayments or deductibles from covered persons or enrollees pursuant to the policy or the evidence of coverage, or of the providers’ obligations, if any, to notify covered persons or enrollees of their personal financial obligations for non-covered services.
(o) A health insurance organization or issuer shall not penalize a provider because the provider, in good faith, reports to Commonwealth and federal authorities any act or practice by the health insurance organization or issuer that jeopardizes patient health or welfare.
(p) A health insurance organization or issuer shall establish a mechanism whereby participating providers may determine in a timely manner whether or not a person is covered by the health insurance organization or issuer.
(q) A health insurance organization or issuer shall establish procedures for resolution of administrative, payment or other disputes with providers.
(r) A contract between a health insurance organization or issuer and a provider shall not contain definitions or other provisions that conflict with the definitions or provisions contained in the managed care plan or this Code.
(s) A health insurance organization or issuer shall include in their contracts with participating providers an adequate summary of the benefit coordination clause, which shall be governed by the provisions of the current NAIC’s Model Act and the federal laws regarding the coordination of benefits. Participating providers shall be responsible for coordinating benefits with health insurance organizations or issuers in the event a covered person or enrollee has coverage under two (2) or more health plans.
History —Aug. 29, 2011, No. 194, added as § 26.060 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9467/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9467 - Intermediaries
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9467 - Intermediaries
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A contract between a health insurance organization or issuer and an intermediary shall satisfy all the requirements contained in this section:
(a) Intermediaries and participating providers with whom they contract shall meet all the requirements of § 9466 of this title.
(b) A health insurance organization or issuer’s responsibility to monitor the offering of healthcare services to covered persons or enrollees shall not be delegated or assigned to the intermediary.
(c) In exercising its freedom of contract, a health insurance organization or issuer shall have the right to approve or disapprove participation of a provider or a provider network contracted by the intermediary. Reasons to disapprove the participation of a particular participating provider include, but are not limited to:
(1) License to practice medicine or profession has been revoked or suspended upon a final and binding determination by competent authorities;
(2) the provider has been arrested or convicted of a felony or misdemeanor involving moral turpitude;
(3) the provider was a participating provider in the health insurance organization or issuer’s network and was expelled therefrom due to breach of contract, fraud or other grounds;
(4) the provider is among the listing of providers excluded from participation in federal health programs or any other similar federal listing;
(5) the provider’s misconduct toward covered persons or enrollees, and
(6) the provider has incurred unfair debt collection practices with respect to the health insurance organization or issuer or covered persons or enrollees.
(d) A health insurance organization or issuer shall maintain copies of all intermediary healthcare subcontracts at its principal place of business in Puerto Rico, or ensure that it has access to all intermediary subcontracts, including the right to make copies to facilitate regulatory review.
(e) If applicable, an intermediary shall furnish utilization documentation and claims paid documentation to the health insurance organization or issuer. The health insurance organization or issuer shall monitor the timeliness and appropriateness of payments made to providers and healthcare services received by covered persons or enrollees.
(f) If applicable, an intermediary shall maintain the books, records, financial information, and documentation of services provided to covered persons or enrollees at its principal place of business in Puerto Rico and preserve them as provided in § 952f of this title in a manner that facilitates regulatory review.
(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 or enrollees, as necessary to determine compliance with this chapter.
(h) A health insurance organization or issuer shall have the right, in the event of the intermediary’s insolvency, to require the assignment to the health insurance organization or issuer of the contract provisions addressing the provider’s obligation to furnish covered services.
History —Aug. 29, 2011, No. 194, added as § 26.070 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9468/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9468 - Filing requirements and state administration
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9468 - Filing requirements and state administration
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(a) Beginning on the effective date of this chapter, a health insurance organization or issuer shall file with the Commissioner sample contract forms proposed for use with its participating providers and intermediaries, so that the Commissioner may ascertain compliance with the provisions of this chapter.
(b) A health insurance organization or issuer shall submit material changes to a contract that would affect a provision required by this chapter or regulations thereunder to the Commissioner for approval sixty (60) days prior to use. For purposes of this subsection, changes in provider payment rates, coinsurance, copayments or deductibles, or other plan benefit modifications shall not be considered material changes.
(c) If the Commissioner takes no action within sixty (60) days after submission of a material change to a contract by a health insurance organization or issuer, the change is deemed approved.
(d) The health insurance organization or issuer shall maintain provider and intermediary contracts at its principal place of business in Puerto Rico, or in a readily accessible place.
History —Aug. 29, 2011, No. 194, added as § 26.080 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9469/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9469 - Contracting
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9469 - Contracting
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(a) The execution of a contract shall not relieve the health insurance organization or issuer of its liability to any person with whom it has contracted for the provision or coverage of services, nor of its responsibility for compliance with the law or applicable regulations.
(b) All contracts shall be in writing and subject to review.
(c) All contracts shall meet the requirements of the applicable laws and regulations.
History —Aug. 29, 2011, No. 194, added as § 26.090 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9470/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9470 - Enforcement of this chapter
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9470 - Enforcement of this chapter
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(a) If the Commissioner determines that a health insurance organization or issuer has not contracted with enough participating providers to assure that covered persons or enrollees have accessible healthcare services in a geographic area, or that a health insurance organization or issuer’s access plan does not assure reasonable access to covered benefits, or that a health insurance organization or issuer has entered into a contract that does not comply with this chapter, or that a health insurance organization or issuer has not complied with the provisions of this chapter, the Commissioner may institute a corrective action or may use any other powers under this Code or the Insurance Code of Puerto Rico to enforce compliance of the health insurance organization or issuer with this chapter.
(b) The Commissioner shall not act to arbitrate, mediate or settle disputes regarding a decision not to include a provider in a managed care plan or in a provider network or regarding any other dispute between a health insurance organization or issuer and a provider arising under or by reason of termination of a contract between them.
History —Aug. 29, 2011, No. 194, added as § 26.100 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-124/9471/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471)›§ 9471 - Effective date
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9471 - Effective date
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(a) All contracts between a health insurance organization or issuer and provider or intermediary in effect shall comply with this chapter not later than eighteen (18) months after the effective date of this chapter. The Commissioner may grant an extension of six (6) months, if the health insurance organization or issuer demonstrates good cause therefor.
(b) Any contract entered into or put in force on the effective date of this chapter shall comply with the provisions of this chapter.
History —Aug. 29, 2011, No. 194, added as § 26.140 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9501/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 126 - External Review (§§ 9501 — 9517)›§ 9501 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9501 - Title
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This chapter shall be known and may be cited as the chapter on External Review.
History —Aug. 29, 2011, No. 194, added as § 28.010 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9502/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 126 - External Review (§§ 9501 — 9517)›§ 9502 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9502 - Purpose
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The purpose of this chapter is to provide standards for the establishment and maintenance of external review procedures that shall govern in Puerto Rico, to assure that covered persons or enrollees have the opportunity for an independent review of an adverse determination or final adverse determination by health insurance organizations or issuers.
History —Aug. 29, 2011, No. 194, added as § 28.020 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9503/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 126 - External Review (§§ 9501 — 9517)›§ 9503 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9503 - Definitions
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For purposes of this chapter:
(a) Certification.— Means a document that contains a determination by a health insurance organization or issuer or its designee utilization review organization that the request for healthcare service or the healthcare service provided has been reviewed and, based on the information furnished, such service is covered by the health plan and satisfies the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care and effectiveness.
(b) Clinical review criteria.— Means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by a health insurance organization or issuer to determine the necessity and appropriateness of healthcare services.
(c) Adverse determination.— Means a determination by a health insurance organization or issuer or its designee utilization review organization that based upon the information provided, a request for service or benefit under the health plan does not meet the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care or effectiveness, or its determined to be experimental or investigational and the request for service or benefit is therefore denied, reduced or terminated or payment is not provided, in whole or in part, for such service or benefit.
(d) Final adverse determination.— Means an adverse determination involving a covered benefit that has been upheld by a health insurance organization or issuer, or its designee utilization review organization, at the completion of the health insurance organization or issuer's internal grievance process procedures as set forth in §§ 9391–9400 of this title.
(e) Disclose.— Means to release, transfer or otherwise divulge protected health information to any person other than the individual who is the subject of such information.
(f) Medical or scientific evidence.— Means evidence found in the following sources:
(1) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts.
(2) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE).
(3) Medical journals recognized by the United States Secretary of Health and Human Services pursuant to the Federal Social Security Act.
(4) The following standard reference compendia:
(A) The American Hospital Formulary Service-Drug Information; Therapeutics; and
(B) Drug Facts and Comparisons®;
(C) The American Dental Association Accepted Dental
(D) The United States Pharmacopoeia-Drug Information;
(5) Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including:
(A) The Federal Agency for Healthcare Research and Quality;
(B) The National Institutes of Health;
(C) The National Cancer Institute;
(D) The National Academy of Sciences;
(E) The Centers for Medicare & Medicaid Services (CMS);
(F) The Federal Food and Drug Administration (FDA); and
(G) Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of healthcare services; or
(6) Any other medical or scientific evidence that is comparable to the sources listed in clauses (1)–(5) of this subsection.
(g) Health information.— Means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relates to:
(1) The past, present or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family;
(2) the provision of healthcare services to an individual, or
(3) payment for the provision of healthcare services to an individual.
(h) Protected health information.— Means health information:
(1) That identifies an individual who is the subject of the information, or
(2) with respect to which there is a reasonable basis to believe that the information could be used to identify an individual.
(i) Case management.— Means a coordinated set of activities established by the health insurance organization or issuer conducted for individual patient management of complicated, protracted or other health conditions.
(j) Utilization review organization.— Means an entity contracted to conduct utilization reviews, other than a health insurance organization or issuer performing a review for its own health plans. It shall not be construed as a requirement for a health insurance organization or issuer to subcontract an independent entity to conduct the utilization review process.
(k) Independent review organization.— Means an entity that conducts independent external reviews of adverse determinations and final adverse determinations issued by a health insurance organization or issuer, or its designee utilization review organization.
(l) Discharge planning.— Means the formal process for determining, prior to discharge from a healthcare facility, the coordination and management of the care that a patient receives following discharge from a facility.
(m) Concurrent review.— Means utilization review conducted during a patient's stay or course of treatment in a healthcare facility, the office of a healthcare professional, or other inpatient or outpatient healthcare setting.
(n) Ambulatory review.— Means utilization review of healthcare services performed or provided in an outpatient setting.
(o) Utilization review.— Means a set of formal techniques designed to monitor healthcare services, procedures, or facilities or to evaluate the medical necessity, appropriateness, efficacy, or efficiency thereof. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review.
(p) Prospective review.— Means utilization review conducted prior to the provision of a healthcare service or a course of treatment, in accordance with a health insurance organization or issuer's requirement that such healthcare service or course of treatment, in whole or in part, be approved prior to its provision.
(q) Retrospective review.— Means any review of a request for a benefit that is not a prospective review request. Retrospective Review does not include the review of a claim that is limited to veracity of documentation or accuracy of coding.
(r) Second opinion.— Means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed healthcare service to assess the medical necessity and appropriateness of the initial proposed healthcare service.
History —Aug. 29, 2011, No. 194, added as § 28.030 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9504/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 126 - External Review (§§ 9501 — 9517)›§ 9504 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9504 - Applicability and scope
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(a) Except as provided in subsection (b) of this section, this chapter shall apply to all health insurance organizations or issuers.
(b) The provisions of this chapter shall not apply to a group or individual policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity, long-term care insurance, vision care or any other limited supplemental benefit or to a Medicare supplement policy of insurance, coverage under a plan through Medicare, Medicaid, or the federal employees health benefits program, any coverage issued under chapter 55 of Title 10, U.S. Code (medical and dental care for the members and former members of the uniformed services and their dependents) and any coverage issued as supplement to that coverage, any coverage issued as supplemental to liability insurance, workers' compensation or similar insurance, automobile medical-payment insurance or any insurance under which benefits are payable with or without regard to fault.
History —Aug. 29, 2011, No. 194, added as § 28.040 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9505/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 126 - External Review (§§ 9501 — 9517)›§ 9505 - Notice of right to external review
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9505 - Notice of right to external review
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(a)
(1) A health insurance organization or issuer shall notify the covered persons or enrollees in writing of the covered person or enrollee's right to request an external review to be conducted pursuant to this chapter. Such notification shall be made when the health insurance organization or issuer sends written notice of any of the following:
(A) An adverse determination upon completion of the utilization review process set forth in §§ 9421–9433 of this title.
(B) A final adverse determination.
(C) In the event of recission of coverage.
(2) As part of the written notice required under clause (1) above, a health insurance organization or issuer shall include the following, or substantially equivalent, language:
“We have denied your request for the provision of or payment for a healthcare service or course of treatment. You may have the right to have our decision reviewed by healthcare professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, healthcare setting, level of care or effectiveness of the healthcare service or treatment you requested by submitting a request for external review to the Office of the Insurance Commissioner. If you need additional information, you may contact the Office of the Insurance Commissioner of Puerto Rico.” If the health insurance organization or issuer, in compliance with federal law, has contracted an independent review organization or has availed itself of the independent review established by the Federal Department of Health, the notice shall be modified to specify the entity and contact information to which the enrollee shall submit an application for external review. A health insurance organization or issuer shall have sixty (60) days after the effective date of this chapter to notify the Office of the Insurance Commissioner of the independent external review procedure chosen. In the event that a private independent review organization is contracted, the name and credentials of the contracted organizations shall be specified.
(3) The Commissioner shall provide the form and content of the notice required under this section.
(b)
(1) The health insurance organization or issuer shall include in the notice required under subsection A, as appropriate:
(A) For a notice related to an adverse determination, a statement informing the covered person or enrollee, as applicable, that:
(i) If the covered person or enrollee has a medical condition where the timeframe for completion of an expedited review of a grievance, as set forth in § 9400 of this title, would seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, the covered person or enrollee may file a request for an expedited external review to be conducted pursuant to § 9509 of this title or § 9510 of this title, as appropriate. In these cases, the independent review organization assigned to conduct the expedited external review shall determine whether the covered person or enrollee shall be required to complete the expedited review of the grievance, as provided in § 9400 of this title, prior to conducting the expedited external review, and
(ii) the covered person or enrollee may file a grievance under the health insurance organization or issuer's internal grievance process as set forth in § 9397 of this title. However, if the health insurance organization or issuer has not issued a written decision within thirty (30) days following the date the covered person or enrollee files the grievance, the covered person or enrollee may file a request for external review, since it shall be considered to have exhausted the internal grievance process for purposes of § 9507 of this title.
(B) For a notice related to a final adverse determination, a statement informing the covered person or enrollee, as applicable, that:
(i) If the covered person or enrollee has a medical condition where the timeframe for completion of a standard external review pursuant to § 9508 of this title, would seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, the covered person or enrollee may file a request for an expedited external review pursuant to § 9509 of this title, or
(ii) if the final adverse determination concerns:
(I) Emergency services received in a healthcare facility, from which the covered person or enrollee has not been discharged, he/she may request an expedited external review pursuant to § 9509 of this title, or
(II) a denial of coverage based on a determination that the recommended or requested healthcare service or treatment is experimental or investigational, the covered person or enrollee may file a request for a standard external review to be conducted pursuant to § 9510 of this title, or if the covered person or enrollee's treating physician certifies in writing that the recommended or requested healthcare service or treatment that is the subject of the request would be significantly less effective if not promptly initiated, the covered person or enrollee may request an expedited external review to be conducted under § 9510 of this title.
(2) In addition to the information to be provided pursuant to subsections (a) and (b) of this section, the health insurance organization or issuer shall include a description of both the standard and expedited external review procedures highlighting the provisions that give the covered person or enrollee the opportunity to submit additional information. It shall also include the forms used to process an external review, if any.
(3) As part of any forms provided under clause (2) of this subsection, the health insurance organization or issuer shall include an authorization form, or other document approved by the Commissioner whereby the covered person or enrollee authorizes the health insurance organization or issuer to disclose protected health information, including medical records, that are pertinent to the external review.
History —Aug. 29, 2011, No. 194, added as § 28.050 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9506/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 126 - External Review (§§ 9501 — 9517)›§ 9506 - Request for external review
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9506 - Request for external review
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(a) All requests for external review shall be made to the Commissioner or in accordance with the review process adopted by the health insurance organization or issuer in compliance with the applicable federal law. The Commissioner may provide the form and content of external review requests.
(b) A covered person or enrollee may make a request for an external review of an adverse determination or final adverse determination, in accordance with § 9505 of this title.
History —Aug. 29, 2011, No. 194, added as § 28.060 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
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