Emergency medical service providers generally cannot bill enrollee amounts beyond in-network cost-sharing, and health care insurers must pay out-of-network providers on time and give required claim notices.
(a)(1) Payment in accordance with Section 27-65-2 shall be payment in full for covered services. (2) An emergency medical service provider, whether in-network or out-of-network, including the provider’s agent, contractor, or assignee, may not bill or seek collection of any amount from an enrollee except for the enrollee’s in-network cost-sharing amount. (3) The health care insurer shall certify an enrollee’s in-network cost-sharing amount to an out-of-network provider upon request. (b)(1) Not later than 30 days after receipt of a clean electronic claim, or not later than 45 days after receipt of a clean written claim, a health care insurer shall remit payment to an out-of-network emergency medical service provider and shall not send payment to an enrollee. (2) If a claim for reimbursement submitted by an emergency medical service provider to a health care insurer is not a clean claim, not later than 30 days after receiving the claim, the health care insurer shall send the provider a written receipt acknowledging the claim, accompanied with one of the following applicable statements: a. The insurer is declining to pay all or a part of the claim, with the specific reason for the denial. b. Additional information is necessary to determine if the claim is payable, with the specific additional information that is required. (3) In no event shall a health care insurer require the provider to submit either of the following as a condition to the acceptance and processing of an initial claim as a clean claim: a. Data elements in excess of those required on the standard electronic health insurance claim format designated by Section 27-1-16. b. Information or data elements in excess of those required on the standard health insurance claim form designated by Section 27-1-16. (4) Any dispute between a health care insurer and an emergency medical service provider over the amount to be paid, or over full or partial denial of a claim, may be settled by: a. Affording the provider access to the insurer’s internal forum for resolving provider disputes concerning coverage and reimbursement amounts; and b. If the dispute is not resolved in the insurer’s internal forum, submission of the dispute to an independent dispute resolution contractor selected by mutual agreement of the insurer and the provider.