20-3456. Covered services; claims; payment; disclosure

345 words·~2 min read·/az/title-20/20-3456

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

A. A provider may receive payment from a health insurer pursuant to this section for services that were provided from the date that was included on the notice of complete credentialing application to the date the provider's network participation contract is executed. A health insurer shall process a provider's claim as an in-network claim and pay the claim if all of the following apply:

1. The provider has applied for credentialing with the health insurer and renders a covered service to an individual who is an eligible health plan member on the date of service.

2. The provider renders the service on or after the date on which the health insurer notified the provider that the application was a complete credentialing application.

3. The provider does not submit the claim until after the provider has a fully executed network participation contract with the health insurer for the member's health plan network and the health insurer has approved the provider's credentials.

B. If a claim is submitted within one year after the date of service, a health insurer may not deny a provider's claim that is submitted in compliance with this section on the basis that the claim was not submitted within the contractually required time period.

C. This section does not require a health insurer to reimburse the applicant at the in-network rate for any covered medical services provided by the applicant if the applicant's credentialing application is not approved or the health care provider is unwilling to contract with the insurer on mutually acceptable terms.

D. Within a reasonable period before a health care provider provides service to a patient in a network facility, a health care provider or the health care provider's representative shall provide a written, dated disclosure that informs the patient of all of the following:

1. The name of the billing health care provider.

2. The total estimated cost to be billed by the health care provider or the health care provider's representative.

3. A statement that the health care provider is not credentialed and is not a contracted provider.