(a) Intermediaries and participating providers with whom they contract shall comply with all the applicable requirements of section 431:26-104.
Terms Used In Hawaii Revised Statutes 431:26-106
carrier: includes an accident and health or sickness insurer that issues health benefit plans under part I of article 10A of this chapter, a mutual benefit society under article 1 of chapter 432, and a health maintenance organization under chapter 432D. See Hawaii Revised Statutes 431:26-101
Contract: A legal written agreement that becomes binding when signed.
Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a physical, mental, or behavioral health condition, illness, injury, or disease, including mental health and substance use disorders. See Hawaii Revised Statutes 431:26-101
Intermediary: means a person authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network, if applicable. See Hawaii Revised Statutes 431:26-101
Network: means the group or groups of participating providers providing services under a network plan. See Hawaii Revised Statutes 431:26-101
Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
(b) A health carrier‘s statutory responsibility to monitor the offering of covered benefits to covered persons shall not be delegated or assigned to the intermediary.(c) A health carrier shall have the right to approve or disapprove participation status of a subcontracted provider in the carrier’s own network or a contracted network for the purpose of delivering covered benefits to the carrier’s covered persons.(d) A health carrier shall maintain copies of all intermediary health care subcontracts at its principal place of business in the State or ensure that the carrier has access to all intermediary subcontracts, including the right to make copies to facilitate regulatory review, upon twenty days’ prior written notice from the health carrier.(e) If applicable, an intermediary shall transmit utilization documentation and claims paid documentation to the health carrier. The carrier shall monitor the timeliness and appropriateness of payments made to providers and health care services received by covered persons.(f) If applicable, an intermediary shall maintain the books, records, financial information, and documentation of services provided to covered persons at its principal place of business in the State and preserve them for the time period required by law in a manner that facilitates regulatory review.(g) An intermediary shall allow the commissioner access to the intermediary’s books, records, financial information, and any documentation of services provided to covered persons, as necessary to determine compliance with this article.(h) If an intermediary is insolvent, a health carrier may require the assignment to the health carrier of the provisions of a provider’s contract addressing the provider’s obligation to furnish covered services. If a health carrier requires assignment, the health carrier shall remain obligated to pay the provider for furnishing covered services under the same terms and conditions as the intermediary prior to the insolvency.(i) Notwithstanding any other provision of this section to the contrary, to the extent the health carrier delegates its responsibilities to the intermediary, the carrier shall retain full responsibility for the intermediary’s compliance with this article.
