TO:
North Carolina Licensed HMOs
North Carolina Licensed Insurers Offering PPO Benefit Plans
FROM:
Cheryl Allen-Bivens, Market Analyst
Donna Tucker, Market Analyst
Market Regulation Division
RE:
NCGS 58-3-191 (“Managed care reporting and disclosure requirements.”)
The Market Regulation Division of the North Carolina Department of Insurance has posted the 2013 managed
care annual filing documents for reporting data year 2012 results. Pursuant to NCGS 58-3-191, completed
filings are due on or before May 1, 2013 by 5:00 p.m. EDT. These files can be downloaded from the
Department’s website: (http://www.ncdoi.com/MR/MR_MC_Annual_Requirments.aspx). If an Insurer believes
their company should be exempt from an annual filing, a request for exemption must be received by the
Department on or before the deadline of March 15, 2013 by 5:00 p.m. EDT. A request must be submitted on the
Insurer’s letterhead with the reason(s) for exemption and signed by an officer of the company. The request must
be sent to the attention of your company’s assigned Market Analyst, either Cheryl Allen-Bivens via email
[email protected] or Donna Tucker via email [email protected], as indicated in your Call
Letter previously submitted to you via email. An exemption request is only valid for the specified data year.
An exemption request must be submitted for each applicable data year.
North Carolina domestic Carriers and foreign Carriers that have and are utilizing their North Carolina domestic
HMO or PPO affiliate should use the file labeled “Domestic2012InstructionsFullService.doc” or
“Domestic2012InstructionsSingleService.doc”. Foreign Carriers that do not have and/or utilize a North
Carolina domestic HMO or PPO affiliate must use the file labeled “Foreign2012InstructionsFullService.doc”
or “Foreign2012InstructionsSingleService.doc”.
If you are a Carrier that has never submitted an Annual Filing, or if you are an existing Carrier that added/
replaced an Intermediary or added a new product line (i.e. Dental or Vision), you must complete the
supplemental form labeled “InitialFilers&NewIntermediaryForm2012.doc”.
The filing must be submitted via email to [email protected] and must be received no
later than May 1, 2013 by 5:00 p.m. EDT. It is important to note that late, incomplete and/or noncompliant filings may be subject to a monetary penalty as outlined in NCGS 58-2-70. You must ensure that
you are completing the applicable 2012 document versions, and that you read the instructions for each item
carefully to ensure all necessary information is provided. Feel free to contact your company’s assigned Market
Analyst: Cheryl Allen-Bivens at (919) 807-6891 ([email protected]) or Donna Tucker, at (919)
807-6897 ([email protected]), as indicated in your Call Letter previously submitted to you via email, if
you have any questions or concerns.
If the Department's Market Regulation Division has performed a market conduct examination of your company
within the past year, we strongly encourage you to discuss and review this filing with your company's exam
coordinator, to ensure that information submitted in this filing is consistent with information furnished during
the examination.
0/03/01
1
ANNUAL MANAGED CARE DATA FILING (NCGS 58-3-191)
Throughout these materials, the terms “Plan,” “Carrier” and “Insurer” refer to the licensed HMO or Insurer responsible for the filing.
ON WHICH PRODUCTS, MEMBERSHIP AND FILING PERIOD SHOULD REPORTING BE BASED?
This filing (NCGS 58-3-191), due on 5/1/2013 by 5:00 p.m. EDT, is required for licensed HMOs and licensed insurers offering PPO
benefit plans in NC.
1. Plan’s reporting must be based on commercial-insured individual and group membership covered under master contracts sitused
in North Carolina; also, commercial-insured must include insureds covered under group trust master contracts sitused out-of-state
but marketed to North Carolina residents. Includes insureds living or working in North Carolina. Reference NCGS 58-3-1 and 583-150. Exclude membership covered under self-funded (non-risk), federally insured, and Medicare or Medicaid plans.
2. Insurers that offer both a full-service and single-service PPO product must submit a separate filing for each.
3. All references to “filing period” shall be defined as January 1, 2012 through December 31, 2012.
FILES NEEDED:
NAME
Domestic2012InstructionsSingleService.doc
TYPE
MS Word
CONTENTS
*General Instructions
*Annual Filing Checklist
*Overall Plan Attestation
*Compliance Certification: Intermediary Arrangements
*Compliance Certification: Provider Availability and
Accessibility
*Compliance Certification: Delegated Provider Availability and
Accessibility
InitialFilers&NewIntermediaryForm2012.doc
MS Word
*Supplemental Checklist ONLY needed if new filer or existing
filer who added/replaced an Intermediary or added a new
product line
2012PlanDataSingleService.xls
MS Excel
*Grids for Plan Data
2012DelegatedDataSingleService.xls
MS Excel
*Grids for Data from Delegated Entities (including Network
Intermediaries, Pharmacy Benefit Managers.)
*The Domestic 2012 Instructions document MUST be sent as MS WORD or .pdf files
*The Plan Data and Delegated Data files MUST be sent as MS Excel files.
Link to NORTH CAROLINA GENERAL STATUTES
Link to NORTH CAROLINA ADMINISTRATIVE RULES
WHERE SHOULD THE COMPLETED FILING BE SENT?
Completed filings must be submitted via email to [email protected] no later than 5/1/2013 by 5 pm EDT.
WHAT IF QUESTIONS ARISE?
General questions about NC filing requirements:
Cheryl Allen-Bivens, Market Analyst, Market Regulation Division, (919) 807-6891 or [email protected]
Donna Tucker, Market Analyst, Market Regulation Division, (919) 807-6897 or [email protected]
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
2
MARKET REGULATION DIVISION
C1. Annual Filing Checklist
Plan
Check-Off
ITEM
#
ITEM NAME
APPLIES TO:
LOCATION
PERIOD
C1. Annual Filing Checklist
Data Year
2012
Included
C1
Included
Annual Filing Checklist
C2
Overall Plan Attestation
C7
Compliance
Certification:
Intermediary
Arrangements including
Pharmacy Benefit
Managers
Included
N/A
Plan only
Plan only
C2. Overall Attestation
Data Year
2012
ITEM INSTRUCTIONS / PLAN COMMENTS
http://www.ncdoi.com/MR/MR_MC_Annual_Requirments.aspx
Submit this Checklist along with the Plan's check-offs.
Submit with all requested information. Two Company officers’
signatures/dates are required.
Submit one Intermediary Arrangements Compliance Certification
for each Intermediary used during any part of the specified data
year.
Plan only
C7. Compliance Certification:
Intermediary Arrangements
Data Year
2012
Explain if N/A:
Submit one Provider Availability and Accessibility Compliance
Certification for the Plan and each intermediary if the Plan set the
targets for any part of the specified data year.
Included
C8
N/A
Compliance
Certification: Provider
Availability and
Accessibility
Compliance
Certification: Delegated
Provider Availability
and Accessibility
List the Delegated Entity(s):
Included
N/A
C9
Entity:
Entity:
Plan only
(Use when targets
are set by the
Plan.)
C8. Compliance Certification: Provider
Availability and Accessibility
Data Year
2012
Explain if N/A:
Submit one Delegated Provider Availability and Accessibility
Compliance Certification if the Intermediary set the targets and
monitored provider availability and accessibility during any part of
the specified data year.
Plan only
(Use when targets
are set by the
Intermediary or
Delegated
Entity.)
Explain if N/A:
C9. Compliance Certification: Delegated
Provider Availability and
Accessibility
Data Year
2012
Entity:
Entity:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
3
Plan
Check-Off
ITEM
#
ITEM NAME
D1
Enrollment/
Disenrollment Summary
for 2012
Plan only
Plan: Grid D1,
2012PlanDataSingleService.xls
As of
12/31/12
D2
Enrollment by County @
12/31/12
Plan only
Plan: Grid D2,
2012PlanDataSingleService.xls
As of
12/31/12
Plan
Plan: Grid D6,
2012PlanDataSingleService.xls
Included
N/A
APPLIES TO:
LOCATION
PERIOD
ITEM INSTRUCTIONS / PLAN COMMENTS
http://www.ncdoi.com/MR/MR_MC_Annual_Requirments.aspx
Included
N/A
Included
D6
N/A
Providers by County @
12/31/12
and/or
Intermediary(s)
Plan
Included
D7
Unique Providers on
Network (State-wide)
and/or
N/A
Intermediary(s)
Included
D8
N/A
Providers Leaving
Network During 2012,
by Reason and Provider
Type
Plan
and/or
Intermediary(s)
Plan
Included
D9
N/A
Providers Joining
Network During 2012,
by Provider Type
and/or
Intermediary(s)
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
Intermediaries: Grid D6,
2012DelegatedDataSingleService.xls
As of
12/31/12
Plan: Grid D7,
2012PlanDataSingleService.xls
Intermediaries: Grid D7,
2012DelegatedDataSingleService.xls
As of
12/31/12
Plan: Grid D8,
2012PlanDataSingleService.xls
Intermediaries: Grid D8,
2012DelegatedDataSingleService.xls
Data Year
2012
Plan: Grid D9,
2012PlanDataSingleService.xls
Intermediaries: Grid D9,
2012DelegatedDataSingleService.xls
Data Year
2012
4
Plan
Check-Off
ITEM
#
Included
D10
N/A
Included
D11
N/ A
Included
D12
N/A
Included
D13
N/A
Included
D14
N/A
Included
D15
N/A
ITEM NAME
Network Density:
Plan/Intermediary
Targets, by Provider
Type and Geographic
Area
Network Density:
Actual
Plan/Intermediary
Performance, by
Provider Type and
Geographic Area
Driving Distance:
Plan/Intermediary
Targets, by Provider
Type and Geographic
Area
Driving Distance:
Actual
Plan/Intermediary
Performance, by
Provider Type and
Geographic Area
Appointment Wait
Times:
Plan/Intermediary
Targets, by Provider
Type and Appointment
Type
Appointment Wait
Times: Actual
Plan/Intermediary
Performance, by
Provider Type and
Appointment Type
APPLIES TO:
Plan
and/or
Intermediary(s)
Plan
LOCATION
Plan
and/or
Intermediaries
Plan
and/or
Intermediaries
Plan
Intermediaries: Grid D10,
2012DelegatedDataSingleService.xls
Plan: Grid D11,
2012PlanDataSingleService.xls
Intermediaries: Grid D11,
2012DelegatedDataSingleService.xls
Plan
Intermediaries: Grid D12,
2012DelegatedDataSingleService.xls
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
As of
12/31/12
Data Year
2012
Plan: Grid D13,
2012PlanDataSingleService.xls
Intermediaries: Grid D13,
2012DelegatedDataSingleService.xls
Plan: Grid D14,
2012PlanDataSingleService.xls
Intermediaries: Grid D14,
2012DelegatedDataSingleService.xls
Plan: Grid D15,
2012PlanDataSingleService.xls
and/or
Intermediaries
Data Year
2012
Plan: Grid D12,
2012PlanDataSingleService.xls
and/or
Intermediaries
ITEM INSTRUCTIONS / PLAN COMMENTS
http://www.ncdoi.com/MR/MR_MC_Annual_Requirments.aspx
Plan: Grid D10,
2012PlanDataSingleService.xls
and/or
Intermediaries
PERIOD
Intermediaries: Grid D15,
2012DelegatedDataSingleService.xls
As of
12/31/12
Data Year
2012
Data Year
2012
5
Plan
Check-Off
ITEM
#
ITEM NAME
D16
Percentage of Providers
Under Each
Compensation Model, by
Provider Type
Included
N/A
APPLIES TO:
Plan
D17
N/A
Range of Withholds and
Bonuses, by
Compensation Model
Intermediaries
D18
N/A
List of Plan’s Delegated
Entities and
Intermediaries
Intermediaries: Grid D16,
2012DelegatedDataSingleService.xls
Plan: Grid D17,
2012PlanDataSingleService.xls
and/or
Intermediaries
Included
Plan: Grid D16,
2012PlanDataSingleService.xls
and/or
Plan
Included
LOCATION
Plan
Intermediaries: Grid D17,
2012DelegatedDataSingleService.xls
Plan: Grid D18,
2012PlanDataSingleService.xls
PERIOD
ITEM INSTRUCTIONS / PLAN COMMENTS
http://www.ncdoi.com/MR/MR_MC_Annual_Requirments.aspx
As of
12/31/12
As of
12/31/12
N/A if the compensation model is fee-for-service without withhold
or bonus.
Data Year
2012
Refer to the Department’s closure letter with the attachment of the
final findings from the previous data year.
Included
N/A
N/A
Outstanding issues from
the previous data year
being addressed and any
requested information
being submitted
Included
N/A
N/A
Supplemental Checklist
Plan
If previous filing
was closed other
than “Accepted”
New Filers or
Existing Filers
who
added/replaced an
Intermediary or
added a new
product line
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
N/A
N/A
Submit one form for each new Initial Operations Filing or
new/replacing Intermediary Filing.
InitialFilers&NewIntermediaryForm2012
Data Year
2012
6
MARKET REGULATION DIVISION
C2. Overall Attestation
(Required From All Plans Submitting a Filing. Plans that are under common ownership must submit a
separate executed Attestation for each company.)
We hereby attest that we have reviewed the entire Annual Filing, and that the information being submitted
for the period of January 1, 2012 through December 31, 2012 is true and complete.
The filing must be submitted electronically to the Department‘s mailbox at
[email protected] on or before the deadline of May 1, 2013 by 5:00 p.m. EDT, or the
next business day if May 1st falls on a Saturday, Sunday or holiday. It is important to note that late,
incomplete and/or non-compliant filings may be subject to a monetary penalty as outlined in NCGS 58-270.
Late filings will require a written explanation on the company’s letterhead signed/dated by the
Company’s President at time of submission.
IMPORTANT NOTE: If the previous data year’s filing was closed as “Accepted with Issues” or “Noncompliant”, the Insurer must make sure to address the issues outlined in the Department’s closure letter and
submit any requested information. Unresolved/Unanswered issues, failing to implement corrective action
or compliance issues impacting North Carolina insureds may result in a market inquiry, market conduct
examination and/or administrative penalty.
Name
(Printed Name)
Name
Title (Company Officer)
Signature
(Printed Name)
Title (Company Officer)
Date
Signature
Date
Company Name
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
7
PRIMARY CONTACT INFORMATION
Name of Person Submitting the Filing (Printed)
Title
Street Address
City
State
Zip
Mailing Address
City
State
Zip
(
)
Direct Phone Number
(
)
Toll Free Phone Number including extension
(
)
Fax Number
E-Mail Address
PLEASE PROVIDE A BACKUP CONTACT, OR IF THE PERSON SUBMITTING THE FILING
IS A CONSULTANT, A COMPANY CONTACT MUST BE PROVIDED.
Name of Person (Printed)
Title
Street Address
City
State
Zip
Mailing Address
City
State
Zip
(
)
Direct Phone Number
(
)
Toll Free Phone Number including extension
(
)
Fax Number
E-Mail Address
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
8
MARKET REGULATION DIVISION
C7. Compliance Certification: Intermediary Arrangements
Submit one Certification for each subcontracted Intermediary.
Pursuant to 11 NCAC 20.0204 (“Carrier and Intermediary Contracts”),
(“Carrier”), duly licensed and authorized to do business in
the State of North Carolina, hereby provides notification that it has entered into a subcontractual
relationship with
(“Intermediary”). Carrier certifies to the
Commissioner of the North Carolina Department of Insurance that the Carrier’s contract with the
Intermediary, and the Intermediary’s own program, are fully compliant with all of the Regulations listed and
referenced below.
Note: The actual documentation will be required at the Market Regulation Division’s next scheduled
Market Conduct Examination of the Insurer or at the discretion of the Department.
I.
Applicable Regulations
11 NCAC 20.0204 Carrier and Intermediary Contracts.
(a) If a Carrier contracts with an intermediary for the provision of a network to deliver health care services,
the Carrier shall file with the Division for prior approval its form contract with the intermediary.
The filing shall be accompanied by a certification from the Carrier that the intermediary will, by the
terms of the contract, be required to comply with all statutory and regulatory requirements which apply
to the functions delegated. The certification shall also state that the Carrier shall monitor such
compliance.
(b) A Carrier's contract form with the intermediary shall state that:
(1) All provider contracts used by the intermediary shall comply with, and include applicable provisions
of 11 NCAC 20.0202.
(2) The network Carrier retains its legal responsibility to monitor and oversee the offering of services to
its members and financial responsibility to its members.
(3) The intermediary may not subcontract for its service without the Carrier's written permission.
(4) The Carrier may approve or disapprove participation of individual providers contracting with the
intermediary for inclusion in or removal from the Carrier's own network plan.
(5) The Carrier shall retain copies or the intermediary shall make available for review by the
Department all provider contracts and subcontracts held by the intermediary.
(6) If the intermediary organization assumes risk from the Carrier or pays its providers on a risk basis or
is responsible for claims payment to it providers:
(A) The Carrier shall receive documentation of utilization and claims payment and maintain
accounting systems and records necessary to support the arrangement.
(B) The Carrier shall arrange for financial protection of itself and its members through such
approaches as member hold harmless language, retention of signatory control of the funds to be
disbursed or financial reporting requirements.
(C) To the extent provided by law, the Department shall have access to the books, records, and
financial information to examine activities performed by the intermediary on behalf of the
Carrier. Such books and records shall be maintained in the State of North Carolina.
(7) The intermediary shall comply with all applicable statutory and regulatory requirements that apply to
the functions delegated by the Carrier and assumed by the intermediary.
(c) If a Carrier contracts with an intermediary to provide health care services and pays that intermediary
directly for the services provided, the Carrier shall either monitor the financial condition of the
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
9
intermediary to ensure that providers are paid for services, or maintain member hold harmless
agreements with providers.
11 NCAC 20.0202 Contract Provisions.
All contract forms that are created or amended on or after the effective date of this Section, and all contract
forms that are executed later than six (6) months after the effective date of this Section, shall contain
provisions addressing the following:
(1) Whether the contract and any attached or incorporated amendments, exhibits, or appendices
constitute the entire contract between the parties.
(2) Definitions of technical insurance or managed care terms used in the contract, and whether those
definitions reference other documents distributed to providers and are consistent with definitions
included in the evidence of coverage issued in conjunction with the network plan.
(3) An indication of the term of the contract.
(4) Any requirements for written notice of termination and each party's grounds for termination.
(5) The provider's continuing obligations after termination of the provider contract or in the case of the
Carrier or intermediary insolvency. The obligations shall address:
(a) Transition of administrative duties and records.
(b) Continuation of care, when inpatient care is on-going. If the Carrier provides or arranges for
the delivery of health care services on a prepaid basis, inpatient care shall be continued until
the patient is ready for discharge.
(6) The provider's obligation to maintain licensure, accreditation, and credentials sufficient to meet the
Carrier's credential verification program requirements and to notify the Carrier of subsequent
changes in status of any information relating to the provider's professional credentials.
(7) The provider's obligation to maintain professional liability insurance coverage in an amount
acceptable to the Carrier and notify the Carrier of subsequent changes in status of professional
liability insurance on a timely basis.
(8) With respect to member billing:
(a) If the Carrier provides or arranges for the delivery of health care services on a prepaid basis
under G.S. 58, Article 67, the provider shall not bill any network plan member for covered
services, except for specified coinsurance, copayments, and applicable deductibles. This
provision shall not prohibit a provider and member from agreeing to continue noncovered
services at the member’s own expense, as long as the provider has notified the member in
advance that the Carrier may not cover or continue to cover specific services and the
member chooses to receive the service.
(b) Any provider's responsibility to collect applicable member deductibles, copayments,
coinsurance, and fees for noncovered services shall be specified.
(9) Any provider's obligation to arrange for call coverage or other back-up to provide service in
accordance with the Carrier's standards for provider accessibility.
(10) The Carrier's obligation to provide a mechanism that allows providers to verify member eligibility,
based on current information held by the Carrier, before rendering health care services. Mutually
agreeable provision may be made for cases where incorrect or retroactive information was
submitted by employer groups.
(11) Provider requirements regarding patients' records. The provider shall:
(a) Maintain confidentiality of enrollee medical records and personal information as required by
G.S. 58, Article 39 and other health records as required by law.
(b) Maintain adequate medical and other health records according to industry and Carrier
standards.
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
10
(c) Make copies of such records available to the Carrier and Department in conjunction with its
regulation of the Carrier.
(12) The provider's obligation to cooperate with members in member grievance procedures.
(13) A provision that the provider shall not discriminate against members on the basis of race, color,
national origin, gender, age, religion, marital status, health status, or health insurance coverage.
(14) Provider payment that describes the methodology to be used as a basis for payment to the provider
(for example, Medicare DRG reimbursement, discounted fee for service, withhold arrangement,
HMO provider capitation, or capitation with bonus).
(15) The Carrier's obligations to provide data and information to the provider, such as:
(a) Performance feedback reports or information to the provider, if compensation is related to
efficiency criteria.
(b) Information on benefit exclusions; administrative and utilization management requirements;
credential verification programs; quality assessment programs; and provider sanction
policies. Notification of changes in these requirements shall also be provided by the Carrier,
allowing providers time to comply with such changes.
(16) The provider's obligations to comply with the Carrier's utilization management programs,
credential verification programs, quality management programs, and provider sanctions programs
with the provision that none of these shall override the professional or ethical responsibility of the
provider or interfere with the provider's ability to provide information or assistance to their
patients.
(17) The provider's authorization and the Carrier's obligation to include the name of the provider or the
provider group in the provider directory distributed to its members.
(18) Any process to be followed to resolve contractual differences between the Carrier and the provider.
(19) Provisions on assignment of the contract shall contain:
(a) The provider's duties and obligations under the contract shall not be assigned, delegated, or
transferred without the prior written consent of the Carrier.
(b) The Carrier shall notify the provider, in writing, of any duties or obligations that are to be
delegated or transferred, before the delegation or transfer.
11 NCAC 20.0201 Written Contracts.
(a) All contracts between network plan carriers and health care providers and between network plan
carriers and intermediary organizations offering networks of health care providers to be used by
network plan carriers for the provision of care on a preferred or in-network basis shall be in writing
and shall comply with 11 NCAC 20 .0202 as a condition of such health care providers' and networks'
being listed in the carrier's provider directory.
(b) The form of every contract under Paragraph (a) of this Rule shall be filed with the Division for approval
according to these Rules before it is used.
(c) As used in this Section and in Section .0600 of this Chapter, "Division" means the Life and Health
Division of the Department of Insurance.
11 NCAC 20.0203 Changes Requiring Approval.
All material changes to an approved contract form shall be filed with the Division for approval before use.
For the purpose of this Section, a "material change" includes a change in the means of calculating payment
to the provider (for example, change from fee for service to capitation), a change in the distribution of risk
between parties, or a change in the delegation of clinical or administrative responsibilities.
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
11
Dental Only
NCGS 58-50-290 Health benefit plans or insurers contracting for provision of dental services; no
limitation on fees for noncovered services.
(a) No agreement between an insurer or an entity that writes stand-alone dental insurance and a dentist
for the provision of dental services on a preferred or in-network basis to plan members or insurance
subscribers in connection with coverage under a stand-alone dental plan, but not in connection with
or incidental to coverage under a medical plan or health insurance policy, may require that a dentist
provide services at a fee limited or set by the plan or insurer, unless the services are reimbursed as
covered services under the contract.
(b) For purposes of this section, "covered services" means a service for which reimbursement is
available under an insurer's policy, without regard to contractual limitations by a deductible,
copayment, coinsurance, waiting period, annual or lifetime maximum, frequency limitation,
alternative benefit payment, or other limitation. (2010-138, s. 1.)
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
12
II. Monitoring Activities
IMPORTANT NOTE: Answer the following questions applicable to Data Year 2012
To demonstrate compliance with 11 NCAC 20.0201, 20.0202, 20.0203 and 11 NCAC 20.0204, Carriers
with Intermediary arrangements must provide requested information within the text boxes below for each
contracted Intermediary.
Dental Only: To demonstrate compliance with NCGS 58-50- 290 Carriers with Intermediary arrangements
must provide requested information within the text boxes below for each contracted Intermediary.
Intermediary:
Identify ALL entities subcontracted by the above Intermediary:
Question 1: Identify each version of the Insurer’s internal Policies & Procedures (P&Ps) for
oversight of the Intermediary’s delegated activities other than Provider Availability/Accessibility
effective during the specified data year.
Answer 1:
Name of the Insurer’s Oversight P&Ps, including any identification number/revision date:
Who from the Insurer approved the Oversight P&Ps (i.e. Board of Directors, Committee or Officer)? (Must
provide names and titles):
Date Insurer approved the P&Ps:
Effective Date of P&Ps:
Question 2: When did the Carrier complete its most recent review of the Intermediary’s provider
contract form/template? (Must specify month/year)
Answer 2:
Question 3: When did the Carrier complete its most recent audit sampling of the Intermediary’s
executed provider contracts? (Must specify month/year)
Answer 3:
Question 4: When does the Carrier anticipate conducting its next review of the Intermediary’s
provider contract form/template and audit sampling of executed provider contracts? (Must specify
month/year)
Answer 4:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
13
Question 5: Specify the number of the Intermediary’s executed provider contracts reviewed by the
Carrier.
Answer 5:
Question 6: If a subcontracted Intermediary was utilized, which organization conducted the
oversight of the subcontracted Intermediary’s Policies & Procedures (P&Ps), provider contract
form/template and executed provider contracts (Company/Intermediary and Name/Title)?
How many executed provider contracts were reviewed for compliance and when was the review date
(month/year)?
Answer 6:
Question 7: How (method of communication) and when was the Carrier notified of the oversight
findings of the subcontracted Intermediary?
Answer 7:
Question 8: What was the Company’s rationale in determining the number of executed provider
contracts reviewed as referenced? (Applicable to Questions/Answers #5 and #6)
Answer 8:
Question 9: Identify areas of non-compliance identified in the provider contract template(s), along
with corrective actions taken and/or planned. (Applicable to Questions/Answers #2 and #6)
Answer 9:
Question 10: Identify all deficiencies found in the audit sampling of the executed provider contracts,
along with corrective actions taken and/or planned. (Applicable to Questions/Answers #5 and #6)
Answer 10:
Question 11: Identify the form number(s) of the provider contract template(s) reviewed for
compliance. The form number is located in the lower left-hand corner of the contract. (Applicable
to Questions/Answers #2 and #6)
Answer 11:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
14
Question 12: Were any material changes as defined by 11 NCAC 20.0203 made to any of the executed
provider contracts reviewed in the Insurer’s audit sampling? If “yes”, please provide the SERFF
tracking number for the filing of the revised provider contract. (Applicable to Questions/Answers #5
and #6). If no SERFF tracking number is available, an explanation must be provided.
Answer 12:
Question 13: Were any material changes as defined by 11 NCAC 20.0203 made to the contract
between the Carrier and Intermediary? If “yes”, please provide the approval date and SERFF
tracking number of the Life & Health filing. If no SERFF tracking number is available, an
explanation must be provided.
Answer 13:
Question 14: If the Intermediary paid claims, did the Intermediary hold an active and valid TPA
license for the specified data year? For any questions or concerns regarding this subject please
contact our Life & Health Division for guidance.
Answer 14:
Question 15: If the Carrier pays the Intermediary directly for the services provided, does the Carrier
have in place financial protection for itself and its members through member hold harmless
language? If no, please explain.
Answer 15:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
15
MARKET REGULATION DIVISION
C8. Compliance Certification: Provider Availability and Accessibility
Pursuant to NCGS 58-3-191 (“Managed Care Reporting and Disclosure Reporting Requirements”), 11
NCAC 20.0301 (“Provider Availability Standards”), 11 NCAC 20.0302 (“Provider Accessibility
Standards”), and 11 NCAC 20.0304 (“Monitoring Activities”)
(“Insurer”), duly licensed and authorized to do business in the State of North Carolina, certifies to the
Commissioner of the North Carolina Department of Insurance that its program is fully compliant with all of
the Regulations listed and referenced below.
If applicable, the Carrier hereby provides notification that it has entered into a subcontractual relationship
with
(“Intermediary”) to provide network services utilizing standards and
methodology defined by the Carrier. Carrier certifies to the Commissioner of the North Carolina
Department of Insurance that the Carrier’s contract with the Intermediary, and the Intermediary’s own
program, are fully compliant with all of the Regulations listed and referenced below.
Note: The actual documentation will be required at the Market Regulation Division’s next scheduled
Market Conduct Examination of the Insurer or at the discretion of the Department.
I.
Applicable Regulations
11 NCAC 20.0301 Provider Availability Standards.
Each network plan carrier shall develop a methodology to determine the size and adequacy of the provider
network necessary to serve the members. The methodology shall provide for the development of
performance targets that shall address the following:
(1) The number and type of primary care physicians, specialty care providers, hospitals, and other
provider facilities, as defined by the Carrier.
(2) A method to determine when the addition of providers to the network will be necessary based on
increases in the membership of the network plan Carrier.
(3) A method for arranging or providing health care services outside of the service area when providers
are not available in the area.
11 NCAC 20.0302 Provider Accessibility Standards.
Each Carrier shall establish performance targets for member accessibility to primary and specialty care
physician services and hospital based services. Carriers shall also establish similar performance targets for
health care services provided by providers who are not physicians. Written policies and performance
targets shall address the following:
(1) The proximity of network providers as measured by such means as driving distance or time a
member must travel to obtain primary care, specialty care and hospital services, taking into account
local variations in the supply of providers and geographic considerations.
(2) The availability to provide emergency services on a 24-hour, seven day per week basis.
(3) Emergency provisions within and outside of the service area.
(4) The average or expected waiting time for urgent, routine, and specialist appointments.
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
16
11 NCAC 20.0304 Monitoring Activities.
Each Carrier shall, by means of site visits or review of information gathered by the Carrier, monitor
compliance with this Section and evaluate provider availability and accessibility at least annually to ensure
that the needs of its members are met. Supporting documentation of these activities shall be maintained for
a period of five years or until the completion of the next triennial examination conducted by the
Department, whichever is later.
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
17
II. Monitoring Activities
IMPORTANT NOTE: Answer the following questions applicable to Data Year 2012
To demonstrate compliance with 11 NCAC 20.0301, 20.0302 and 20.0304, Carriers with their own
provider networks or who require its subcontracted Intermediaries to utilize Carrier’s provider accessibility
and availability standards must provide requested information within the text boxes below. Do not attach
additional documentation.
Intermediary:
Question 1: Check which standard(s) were established by the Plan. DO NOT DISCLOSE THE
ACTUAL STANDARDS.
Answer 1:
Network Density
Driving Distance
Appointment Wait Times
Question 2: Identify each version of the Carrier’s Policies & Procedures (P&Ps) for provider
availability and accessibility effective during the specified data year.
Answer 2:
Name of Insurer’s P&Ps, including any identification number/revision date:
Who from the Insurer (i.e. Board of Directors, Committee or Officer) approved the P&Ps? (Must provide
names and titles):
Date Insurer approved the P&Ps:
Effective Date of the P&Ps:
Question 3: When did the Carrier complete its most recent review of its own Policies & Procedures
(P&Ps) regarding provider availability and accessibility? (Must specify month/year)
Answer 3:
Question 4: When does the Carrier anticipate conducting its next review of its own Policies &
Procedures (P&Ps) regarding provider availability and accessibility? (Must specify month/year)
Answer 4:
Question 5: Is the Carrier monitoring the provider availability/accessibility according to the terms
and frequency of the established Policies & Procedures (P&Ps)?
Answer 5:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
18
Question 6: Identify areas of non-compliance in the Carrier’s Policies & Procedures (P&Ps), along
with corrective actions taken and/or planned.
Answer 6:
Question 7: Identify what information (report) was reviewed by the Carrier to determine if the
network density standards for the specified data year were met. This information/report must
support the reported results.
Answer 7:
Question 8: Specify the date of the report, the time period the report covered and when the Carrier
reviewed this information (report) on network density standards and actual results.
Answer 8:
Question 9: Identify any network density standard which was not met and explain what, if any,
corrective active was taken and/or planned.
Answer 9:
Question 10: Identify what information (report) was reviewed by the Carrier to determine if the
driving distance standards for the specified data year were met. This information/report must
support the reported results.
Answer 10:
Question 11: Specify the date of the report, the time period the covered by the report and when the
Carrier reviewed this information (report) on driving distance standards and actual results.
Answer 11:
Question 12: Identify any driving distance standard which was not met and explain what, if any,
corrective active was taken and/or planned.
Answer 12:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
19
Question 13: Specify if a NC member or NC provider survey was used in determining appointment
wait time results.
Answer 13:
Question 14: Specify the date of the survey, the time period the survey covered and when the Carrier
reviewed the survey results on appointment wait times standards.
Answer 14:
Question 15: Disclose the participation rate (# of members/providers surveyed vs. # of respondents).
Answer 15:
Question 16: : Identify any supplemental method used to measure any appointment wait times type
(i.e. reviewing complaints/grievance when not enough responses were received for a valid survey or
cold calls to providers offices’ to measure compliance with contractual emergency provisions to
measure emergency appointment wait times).
Answer 16:
Question 17: Identify any appointment wait times standard which was not met and explain what, if
any, corrective active was taken and/or planned.
Answer 17:
Question 18: Was any standard revised for this reporting year? If “yes”, state the change, the
reason for the change and the date when the change was approved by the Carrier.
Answer 18:
Question 19: State the Carrier or Intermediary’s policy for paying claims for in-network emergency
care? Is prior authorization required?
Answer 19:
Question 20: State the Carrier or Intermediary’s policy for paying claims for out-of-network
emergency care? Is prior authorization required?
Answer 20:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
20
Question 21: What provisions (authorization and claim payment) are made for members when care
by a participating provider cannot be provided within the availability and accessibility standards
and a member seeks care from a non-participating provider? (This includes those counties with
membership but no or limited providers.)
Is prior authorization required?
Does the member have to file a grievance for reimbursement?
Is the member balance billed?
Answer 21:
Question 22: Describe the Carrier’s disclosure provisions to members about receiving care from a
non-participating provider when an in-network provider is not reasonably available (within the
standards for driving distance and/or appointment wait times).
Identify the document used during the reporting period which discloses these provisions (i.e. member
handbook, enrollment material, Certificate, etc.)
Answer 22:
Question 23: If the above Intermediary used a subcontracted entity (as identified in the C7
Certification) and its provider network was used to supplement the Plan’s or Intermediary’s network
(not a standalone network option) were the Company’s answers and provider
availability/accessibility results inclusive of ALL participating providers? If “no”, an explanation
must be provided.
Answer 23:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
21
MARKET REGULATION DIVISION
C9. Compliance Certification: Delegated Provider
Availability and Accessibility
Submit one Certification for each subcontracted Intermediary.
Pursuant to NCGS 58-3-191 (“Managed Care Reporting and Disclosure Reporting Requirements”), 11
NCAC 20.0301 (“Provider Availability Standards”), 11 NCAC 20.0302 (“Provider Accessibility
Standards”), and 11 NCAC 20.0304 (“Monitoring Activities”)
(“Carrier”), duly licensed and authorized to do business in the State of North Carolina, hereby provides
notification that it has entered into a subcontractual relationship with
(“Intermediary”). Carrier certifies to the Commissioner of the North Carolina Department of
Insurance that the Carrier’s contract with the Intermediary, and the Intermediary’s own program, are fully
compliant with all of the Regulations listed and referenced below.
Note: The actual documentation will be required at the Market Regulation Division’s next scheduled
Market Conduct Examination of the Insurer or at the discretion of the Department.
I.
Applicable Regulations
11 NCAC 20.0301 Provider Availability Standards.
Each network plan carrier shall develop a methodology to determine the size and adequacy of the provider
network necessary to serve the members. The methodology shall provide for the development of
performance targets that shall address the following:
(1) The number and type of primary care physicians, specialty care providers, hospitals, and other
provider facilities, as defined by the Carrier.
(2) A method to determine when the addition of providers to the network will be necessary based on
increases in the membership of the network plan Carrier.
(3) A method for arranging or providing health care services outside of the service area when providers
are not available in the area.
11 NCAC 20.0302 Provider Accessibility Standards.
Each Carrier shall establish performance targets for member accessibility to primary and specialty care
physician services and hospital based services. Carriers shall also establish similar performance targets for
health care services provided by providers who are not physicians. Written policies and performance
targets shall address the following:
(1) The proximity of network providers as measured by such means as driving distance or time a
member must travel to obtain primary care, specialty care and hospital services, taking into account
local variations in the supply of providers and geographic considerations.
(2) The availability to provide emergency services on a 24-hour, seven day per week basis.
(3) Emergency provisions within and outside of the service area.
(4) The average or expected waiting time for urgent, routine, and specialist appointments.
11 NCAC 20.0304 Monitoring Activities.
Each Carrier shall, by means of site visits or review of information gathered by the Carrier, monitor
compliance with this Section and evaluate provider availability and accessibility at least annually to ensure
that the needs of its members are met. Supporting documentation of these activities shall be maintained for
a period of five years or until the completion of the next triennial examination conducted by the
Department, whichever is later.
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
22
II. Monitoring Activities
IMPORTANT NOTE: Answer the following questions applicable to Data Year 2012
To demonstrate compliance with 11 NCAC 20.0301, 20.0302 and 20.0304, Carriers with Intermediary
arrangements must provide requested information within the text boxes below for each contracted
Intermediary. Do not attach additional documentation.
Intermediary:
Question 1: Check which standard(s) were established by the Intermediary. DO NOT DISCLOSE
THE ACTUAL STANDARDS.
Answer 1:
Network Density
Driving Distance
Appointment Wait Times
Question 2: Identify each version of the Insurer’s internal Policies & Procedures (P&Ps) for
oversight of the Intermediary’s provider availability and accessibility effective during the specified
data year.
Answer 2:
Name of the Insurer’s Oversight P&Ps, including any identification number/revision date:
Who from the Insurer approved the Oversight P&Ps (i.e. Board of Directors, Committee or Officer)? (Must
provide names and titles):
Date Insurer approved the P&Ps:
Effective Date of P&Ps:
Question 3: Identify each version of the Intermediary’s Policies & Procedures (P&Ps) for provider
availability and accessibility effective during the specified data year.
Answer 3:
Name of the Delegated Entity’s P&Ps, including any identification number/revision date:
Date P&Ps approved internally by the Delegated Entity:
Who from the Delegated Entity approved the P&Ps (i.e. Board of Directors, Committee or Officer)? (Must
provide names and titles):
Effective Date of the Delegated Entity’s P&Ps:
Who from the Insurer (i.e. Board of Directors, Committee or Officer) approved the Delegated Entity’s
P&Ps? (Must provide names and titles):
Date Insurer approved the Delegated Entity’s P&Ps:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
23
Question 4: When did the Carrier complete its most recent review of the Intermediary’s Policies &
Procedures (P&Ps) regarding provider availability and accessibility? (Must specify month/year)
Answer 4:
Question 5: When does the Carrier anticipate conducting its next review of the Intermediary’s
Policies & Procedures (P&Ps) regarding provider availability and accessibility? (Must specify
month/year)
Answer 5:
Question 6: Is the Intermediary monitoring provider availability and accessibility according to the
Policies & Procedures (P&Ps) terms and frequency?
Answer 6:
Question 7: Identify areas of non-compliance in the Intermediary’s Policies & Procedures (P&Ps),
along with corrective actions taken and/or planned.
Answer 7:
Question 8: Identify what information (report) was reviewed by the Carrier to determine if the
network density standards for the specified data year were met. This information/report must
support the reported results.
Answer 8:
Question 9: Specify the date of the report, the time period covered by the report and when the
Carrier reviewed this information (report) on network density standards and actual results.
Answer 9:
Question 10: Identify any network density standard which was not met and explain what, if any,
corrective active was taken and/or planned.
Answer 10:
Question 11: Identify what information (report) was reviewed by the Carrier to determine if the
driving distance standards for the specified data year were met. This information/report must
support the reported results.
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
24
Answer 11:
Question 12: Specify the date of the report, the time period covered by the report and when the
Carrier reviewed this information (report) on driving distance standards and actual results.
Answer 12:
Question 13: Identify any driving distance standard which was not met and explain what, if any,
corrective active was taken and/or planned.
Answer 13:
Question 14: Specify if a NC member or NC provider survey was used in determining appointment
wait time results.
Answer 14:
Question 15: Specify the date of the survey, report, the time period the survey covered and when the
Carrier reviewed this information (report) on appointment wait times standards.
Answer 15:
Question 16: Describe the participation rate (# of members/providers surveyed vs. # of respondents).
Answer 16:
Question 17: Identify any supplemental method used to measure any appointment wait times type
(i.e. reviewing complaints/grievance when not enough responses were received for a valid survey or
cold calls to providers offices’ to measure compliance with contractual emergency provisions to
measure emergency appointment wait times).
Answer 17:
Question 18: Identify any appointment wait times standard which was not met and explain what, if
any, corrective active was taken and/or planned.
Answer 18:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
25
Question 19: Was any standard revised for this reporting year? If “yes”, state the change, the
reason for the change and the date when the change was discussed/approved by Carrier.
Answer 19:
Question 20: State the Carrier or Intermediary’s policy for paying claims for in-network emergency
care? Is prior authorization required?
Answer 20:
Question 21: State the Carrier or Intermediary’s policy for paying claims for out-of-network
emergency care? Is prior authorization required?
Answer 21:
Question 22: What provisions (authorization and claim payment) are made for members when care
by a participating provider cannot be provided within the availability and accessibility standards
and a member seeks care from a non-participating provider? (This includes those counties with
membership but no or limited providers.)
Is prior authorization required?
Does the member have to file a grievance for reimbursement?
Is the member balance billed?
Answer 22:
Question 23: Describe the Carrier’s disclosure provisions to members about receiving care from a
non-participating provider when an in-network provider is not reasonably available (within the
standards for driving distance and/or appointment wait times).
Identify the document used during the reporting period which disclosures these provisions (i.e.
member and book, enrollment material, Certificate, etc.)
Answer 23:
Question 24: If the above Intermediary used a subcontracted entity (as identified in the C7
Certification) and its provider network was used to supplement the Plan’s or Intermediary’s network
(not a standalone network option) were the Company’s answers and provider
availability/accessibility results inclusive of ALL participating providers? If “No”, an explanation
must be provided.
Answer 24:
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
26
NC Dept. of Insurance
Market Regulation Division – Domestic Carriers Single Service
January 2013
27