40-2143. Predetermination of health care benefits act; predetermination request procedures.

528 words·~2 min read·/ks/chapter-40/40-2143

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(a)This section shall be known as and may be cited as the predetermination of health care benefits act.

(1)Health plans that receive an electronic health care predetermination request consistent with the requirements set forth in subsection

(c)shall provide to the requesting healthcare provider information on the amounts of expected benefits coverage on the procedures specified in the request that is accurate at the time of the health plan's response.

(2)Any predetermination request provided under this section in good faith shall be deemed to be an estimate only and shall not be binding upon the health plan with regard to the final amount of benefits actually provided by the health plan.

(c)The amounts for the referenced services in subsection

(b)shall include:

(1)The amount the patient will be expected to pay, clearly identifying any deductible amount, coinsurance and copayment;

(2)the amount the healthcare provider will be paid;

(3)the amount the institution will be paid; and

(4)whether any payments will be reduced, but not to $0, or increased from the agreed fee schedule amounts, and if so, the health care policy that identifies why the payments will be reduced or increased.

(d)This electronic request and response transaction shall be known as the health care predetermination request and response. The health care predetermination request and response shall be conducted in accordance with the transactions and code sets standards promulgated pursuant to the health insurance portability and accountability act of 1996 (HIPAA) public law 104-191, and 45 code of federal regulations, parts 160 and 162 or later versions, specifically, the ASC X12 837 health care predetermination: Professional transaction or the ASC X12 837 healthcare predetermination; institutional and any of their respective successors, without regard to whether this transaction is mandated by HIPAA. It shall also comply with any operating rules that may be adopted with respect to this transaction or any of its successors, without regard to whether these operating rules are mandated by HIPAA.

(e)The health plan's response to the health care predetermination request shall be returned using the same transmission method as that of the submission.

(f)For purposes of this section:

(1)"Health plan" shall have the same meaning as that term is defined in K.S.A. 40-4602 , and amendments thereto;

(2)"healthcare provider" shall have the same meaning as the term "provider" as such term is defined in K.S.A. 40-4602 , and amendments thereto. Healthcare provider shall also include:

(A)An advanced practice registered nurse as defined in K.S.A. 65-1113 , and amendments thereto; and

(B)a physician assistant as defined in K.S.A. 65-28a02 , and amendments thereto; and

(3)"payment" means only a deductible or coinsurance payment and does not include a copayment.

(g)This act precludes the collection of any payment prior to or as a condition of receiving the health benefit services that are the subject of a predetermination request, unless this practice is not prohibited by the provider agreement with the health plan.

(h)The commissioner of insurance shall adopt rules and regulations necessary to carry out the provisions of this section.