Regular Session 2017-2018 Senate Bill 0373 P.N. 1908

HOUSE AMENDED

PRIOR PRINTER'S NOS. 364, 1287

PRINTER'S NO. 1908

THE GENERAL ASSEMBLY OF PENNSYLVANIA

SENATE BILL

No.

373

Session of

2017

INTRODUCED BY EICHELBERGER, GREENLEAF, REGAN, RAFFERTY, COSTA,

BROWNE, ARGALL, MENSCH, WARD, VOGEL, BOSCOLA, RESCHENTHALER,

HUTCHINSON, SCAVELLO, KILLION, BROOKS, AUMENT, McGARRIGLE,

STEFANO, ALLOWAY, BLAKE AND McILHINNEY, FEBRUARY 15, 2017

AS REPORTED FROM COMMITTEE ON INSURANCE, HOUSE OF

REPRESENTATIVES, JUNE 21, 2018

AN ACT

Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An

act relating to insurance; amending, revising, and

consolidating the law providing for the incorporation of

insurance companies, and the regulation, supervision, and

protection of home and foreign insurance companies, Lloyds

associations, reciprocal and inter-insurance exchanges, and

fire insurance rating bureaus, and the regulation and

supervision of insurance carried by such companies,

associations, and exchanges, including insurance carried by

the State Workmen's Insurance Fund; providing penalties; and

repealing existing laws," in uniform health insurance claim

form, further providing for forms for health insurance

claims.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1. Section 1202 of the act of May 17, 1921 (P.L.682,

No.284), known as The Insurance Company Law of 1921, is amended

to read:

Section 1202. Forms for Health Insurance Claims.--(a) Each

health insurance claim form processed or otherwise used by an

insurer, including those used by the Department of [Public

Welfare] Human Services for public health care coverage, shall

be the uniform claim form developed by the department. The claim

form shall be identical in form and content except as provided

in subsection (c). The department shall, in consultation with

the Department of [Public Welfare] Human Services, insurers and

health care providers or their representatives, first consider

the feasibility of utilizing the UB-82/HCFA-1450 and HCFA-1500

forms, or their successors, as a uniform claim form. If these

forms are deemed to be unsatisfactory, the department shall, in

consultation with the Department of [Public Welfare] Human

Services, insurers and health care providers or their

representatives, develop a uniform claim form for use by all

insurers, the Department of [Public Welfare's] Human Services'

public health care coverage program and health care providers.

The uniform claim form shall contain blank spaces at appropriate

places in the document for approved additional information

requests under subsection (c).

(b) The feasibility study and subsequent development of the

uniform claim form shall be complete within one hundred eighty

(180) days of the effective date of this article. All insurers,

the Department of [Public Welfare's] Human Services' public

health care coverage program and health care providers shall be

required to use the uniform claim form within one hundred twenty

(120) days after the uniform claim form is developed. The

department may consider a request from the Department of [Public

Welfare] Human Services for an extension in meeting the

implementation schedule of this section.

an insurer may request that a claimant provide departmentally

approved additional information which is not requested on the

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uniform claim form.

(2) An insurer may request departmental approval of

additional information requests to be printed in the blank

spaces on the uniform claim form, and on subsequent pages if

necessary, by submitting a written request to the department.

Such a request shall be deemed approved by the department if not

disapproved within sixty (60) days after receipt of the request.

A disapproval shall be subject to the procedures under 2 Pa.C.S.

(relating to administrative law and procedure).

(3) If, in a dental claim form, an insured specifically

authorizes payment of benefits directly to an entity or person

who provided dental services in accordance with the provisions

of the policy, the insurer shall make the payment to the

specific provider of the dental services. Insurance contracts

issued 120 days after the effective date of this act may not

prohibit, and claim forms issued after that date must provide an

option for, the payment of benefits directly to the specified

provider of the dental service. The insurer may require written

attestation of the assignment of the payment. Payment to the

specific provider of the dental services from the insurer may

not be more than the amount that the insurer would otherwise

have paid without the assignment of payment. The dental claim

form shall clearly and conspicuously state whether the provider

seeking authorization for direct payment from the insurer will

bill the patient for any balance above the direct payment

assigned to the provider. The insured may be required to pay any

applicable copayments, coinsurances or deductibles at the time

of service, however, the provider shall not require the insured

to pay any other amount above the direct payment assigned to the

provider at the point of service.

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(3) EXCEPT AS PROVIDED IN PARAGRAPH (4), A CHECK FOR PAYMENT

OF A CLAIM COVERED UNDER ANY DENTAL CARE INSURANCE POLICY ISSUED

OR RENEWED ON OR AFTER THE EFFECTIVE DATE OF THIS PARAGRAPH FOR

COVERED DENTAL CARE SERVICES PROVIDED BY A LICENSED DENTAL

PROVIDER, WHERE THE DENTAL PROVIDER IS NOT A PARTICIPATING

PROVIDER UNDER A CONTACT WITH A DENTAL INSURER, SHALL BE MADE

OUT TO BOTH THE DENTAL PROVIDER AND THE INSURED. THE CHECKS

SHALL BE SENT TO THE INSURED. AN OUT-OF-NETWORK DENTAL PROVIDER

SHALL NOT REQUIRE THE INSURED TO PAY ANY AMOUNT ABOVE ANY

APPLICABLE COPAYMENTS, COINSURANCES OR DEDUCTIBLES AT THE TIME

OF SERVICE.

(4) DENTAL INSURANCE POLICIES ISSUED OR RENEWED ON OR AFTER

THE EFFECTIVE DATE OF THIS PARAGRAPH, AND DENTAL CLAIMS FORMS

UNDER THOSE POLICIES, SHALL ALLOW AN OUT-OF-NETWORK PROVIDER OF

THE DENTAL SERVICE TO REQUEST THAT THE DENTAL INSURER ' S PAYMENT

BE MADE ONLY TO THE PROVIDER. WHERE THE INSURED, WITH WRITTEN

ATTESTATION, AGREES TO THE ASSIGNMENT OF PAYMENT, THE PROVIDER

SHALL NOT REQUIRE THE INSURED TO PAY AN AMOUNT IN EXCESS OF THE

INSURER ' S RATE FOR THE SAME SERVICE PERFORMED BY A NETWORK

PROVIDER, EXCEPT FOR ANY APPLICABLE COPAYMENTS, COINSURANCES OR

DEDUCTIBLES.

(5) NOTHING IN PARAGRAPH (3) OR (4) SHALL PRECLUDE A DENTAL

INSURER AND AN OUT-OF-NETWORK DENTAL PROVIDER FROM AGREEING TO

AN ALTERNATE PAYMENT ARRANGEMENT. THE PROVIDER SHALL NOT REQUIRE

THE INSURED TO PAY AN AMOUNT IN EXCESS OF THE INSURER ' S RATE,

EXCEPT FOR ANY APPLICABLE COPAYMENTS, COINSURANCES OR

DEDUCTIBLES.

(d) In the case of vision and dental claim forms and in the

case of supplemental major medical claim forms, utilization of

the uniform claim form shall be at the discretion of the

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individual insurer.

(e) The Legislative Budget and Finance Committee shall

conduct a study to examine all of the following:

(1) The costs and benefits associated with the direct

reimbursement of nonparticipating providers by health insurance

carriers under a valid assignment of benefits.

(2) The impact on consumers of prohibiting health insurance

carriers from refusing to accept a valid assignment of benefits.

(3) The impact of requiring direct reimbursement of

nonparticipating providers by health insurance carriers on a

health insurance carrier's ability to maintain an adequate

number of providers in their network. A report on the study

shall be presented to the chairman and minority chairman of the

Insurance Committee of the House of Representatives and the

chairman and minority chairman of the Banking and Insurance

Committee of the Senate no more than thirty-six months after the

effective date of this subsection.

Section 2. This act shall take effect in 60 240 days.

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