NCDOI Provider and Consumer Assistance /22/2015. Consumer Assistance Group

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1 NCDOI Provider and Consumer Assistance Kathy Shortt, Deputy Commissioner Consumer Services Division, NCDOI Consumer Assistance Group Seniors Health Insurance Information Program (SHIIP) Health Insurance Smart NC Consumer Services Division (CSD) SHIIP Assists Medicare Beneficiaries with their questions and concerns about their Medicare products. Assists with enrollment into Part D Prescription Drug Plans. Counsels on Medicare options, Long Term Care Insurance, Medicare Supplements. 1

2 Health Insurance Smart NC Handles all consumer health insurance complaints. Administers External Review. Actively assists consumers with constructing appeals and grievances. Educates consumers on health insurance products. Hands On assistance. Federal Exchange complaints. CSD Handles inquiries and complaints from consumers and providers for most all insurance products. Health: Group and Individual Disability, Dental, Vision, LTC. Life: Annuities, Universal Life, Auto: Personal/Commercial Homeowners: Personal/Commercial What are the trends for complaints? What should a provider do if they have trouble getting a claim paid? When should a provider contact DOI? What recourse is available to consumers? 2

3 What are the trends for provider complaints? Total A/H Complaints Filed for 2014: 1,500 Total Valid A/H Complaints: 189 (12.6%) Total Provider Complaints for 2014: 294 Total Valid Provider Complaints: 37 (12.6%) What are the trends for provider complaints? Group A/H Delay of Settlement Complaints: 74 Valid Delay of Settlement Complaints: 13 Delay of Claim Complaints: 79 Valid Delay of Settlement Complaints: 5 Individual A/H Delay of Settlement Complaints: 18 Valid Delay of Settlement Complaints: 8 Delay of Claim Complaints: 15 Valid Delay of Claim Complaints: 3 What are the trends for consumer complaints? Prescription Drug Cost Sharing Residential Care Treatment Facilities General Marketplace Concerns 3

4 What should a provider do if they have trouble getting a claim paid? Contact the Provider Relations person at the insurer. Contract is between the provider and insurer. DOI does not get involved with contract disputes/issues. Provider Appeal- is a contractual provision, not a statutory provision. Encourage your patient to get involved with consumer recourse. Look for compliance with statutes, regulations and policy provisions. Look for an insurer s compliance with their own policies and procedures. Prompt Pay Legislation NCGS A claim must be paid, pended or denied in accordance with statutes. An insurer must pay interest at APR of 18% if claim is not paid within 30 days of having the necessary information to make a decision. Insurers may require that claims be submitted within 180 days. 4

5 Provider Credentialing NCGS An insurer that credentials providers for its network shall credential providers within 60 days of receipt of the completed application form approved by the Commissioner (does not apply to facilities). Commissioner shall adopt a uniform credentialing application. No insurer may require an applicant to submit information not required by the uniform credentialing application. Provider Fee Schedules NCGS Requires that an insurer must make available to providers and those applying to be providers the fee schedules for the top 30 services or procedures most commonly billed by that class of provider. An insurer must provide advanced notice to providers and facilities of changes to the information that insurers are required to provide under this section. The Department cannot speak to what a participant s procedure or service is worth. Services Outside Provider Networks NCGS Requires that no insurer penalize an insured or subject an insured to the out-of-network benefit levels offered under the insured s plan unless contracted health care providers able to meet the health needs of the insured are reasonably available to the insured without reasonable delay. 5

6 Mental Illness Benefits Coverage NCGS Requires that an insurer shall provide for the necessary care and treatment of mental illness that are no less favorable than benefits for physical illness generally. Provider Accessibility and Availability 11 NCAC HMO/PPO plans must maintain adequate networks for their covered members. Plans must establish their own standards for provider availability: Number and type of providers. Method for determining when network expansion is necessary. Consumer Appeals NCGS and 62 Member appeals rights and processes are statutorily defined. Providers can act as an Authorized Representative for the consumer. Provider appeals are defined by the health plan contract, not statute. 6

7 When should a provider contact DOI? A provider should contact DOI when they believe that there is an issue of noncompliance with statutes or regulations. DOI cannot act as an intermediary for claims payment. Providers should also encourage their patients to be a participant in the recourse. File complaints online at using the Healthcare Professionals and Facilities tab. What recourse is available to consumers? Health Insurance Smart NC services Vigorous advocacy for consumers. Assistance with education and understanding health plans. Hands-on assistance with constructing appeals and grievances. Can assist with self-funded and State Health plan issues. Assists with Marketplace issues. What recourse is available to consumers? ACA Protections for Mental Health No pre-existing condition exclusions Parity No annual limits 7

8 What recourse is available to consumers? Appeal and Grievance Statutory protections Smart NC staff will help build the appeal or grievance Providers can be named as Authorized Representatives but it remains a consumer recourse. Informal Reconsiderations External Review How do you reach us? Mailing Address: North Carolina Department of Insurance Consumer Services Division 1201 Mail Service Center Raleigh, NC Kathy.Shortt@ncdoi.gov Questions? 8