Chapter 32. Health Insurance Forms.

Subchapter I. Uniform Claims Forms.

§ 31–3201. Standardized uniform health insurance claims forms.

(a) The HCFA 1500 and UB 92 claims forms, or their successor forms as they may be amended from time to time, shall serve as the official health insurance claims forms of the District of Columbia for hospitals and other medical providers and governmental agencies, and such forms shall be used and exclusively accepted by all insurers, including health maintenance organizations and other forms of managed care, transacting health insurance, providing medical insurance through a personal automobile policy, workers’ compensation, or otherwise providing coverage for medical services, and by all hospitals, medical providers, and government agencies in the District of Columbia that require insurance claim forms for their records.

(b) The claims forms specified in subsection (a) of this section may be modified as necessary to accommodate the transmission and administration of claims by electronic means.

(c)(1) No later than January 1, 2024, a utilization review entity shall accept and respond to prior authorization requests under the pharmacy benefit through a secure electronic transmission using the NCPDP SCRIPT Standard ePA transactions, which shall not include facsimile, proprietary payer portals, electronic forms, or any other technology not directly integrated with a physician's electronic health record or electronic prescribing system.

(2) For the purposes of this subsection, the term:

(A) "NCPDP SCRIPT Standard ePA" means the National Council for Prescription Drug Programs SCRIPT Standard Version 2013101, or the most recent standard adopted by the United States Department of Health and Human Services.

(B) "Prior authorization" shall have the same meaning as provided in § 31-3875.01(7).

Subchapter II. Uniform Consultation Referral Forms.

§ 31–3231. Definitions.

For the purposes of this subchapter, the term:

(1) “Health benefit plan” means any accident and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, plan provided by a multiple employer welfare arrangement, or plan provided by another benefit arrangement. The term “health benefit plan” does not mean accident only, credit, or disability insurance; coverage of Medicare services or federal employee health plans, pursuant to contracts with the United States government; Medicare supplemental or long-term care insurance; dental only or vision only insurance; specified disease insurance; hospital confinement indemnity coverage; limited benefit health coverage; coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law; automobile medical payment insurance; medical expense and loss of income benefits; or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(2) “Health insurer” means any person that provides one or more health benefit plans or insurance in the District of Columbia, including an insurer, a hospital and medical services corporation, a fraternal benefit society, a health maintenance organization, a multiple employer welfare arrangement, or any other person providing a plan of health insurance subject to the authority of the Commissioner.

(3) “Commissioner” means the Commissioner of the Department of Insurance and Securities Regulation.

§ 31–3232. Uniform consultation referral forms.

(a) This subchapter shall apply to all health insurers that issue or deliver individual or group health benefit plans in the District of Columbia.

(b) All health insurers that require the insured to have a written referral to receive consultation services shall use the uniform consultation referral form adopted by the Commissioner as the sole instrument for referrals for consultation services.

(c) The uniform consultation referral form shall be properly completed by the health care provider that refers the insured for consultation services.

§ 31–3233. Regulations.

(a) The Commissioner shall promulgate regulations to implement the provisions of this subchapter. The regulations shall include a uniform consultation referral form for use by health insurers that require enrollees or subscribers to have a written referral to receive consultation services.

(b) The Commissioner may waive the requirements of regulations adopted under subsection (a) of this section for the use of uniform consultation referral forms for an entity that uses the forms solely for internal purposes.

§ 31–3234. Applicability.

This subchapter shall apply to health insurers beginning with referrals issued 120 days after the promulgation of final regulations under § 31-3233.

Subchapter III. Uniform Credentialing Forms.

§ 31–3251. Definitions.

For the purposes of this subchapter, the term:

(1) “Commissioner” means Commissioner of the Department of Insurance and Securities Regulation.

(2) “Credentialing intermediary” means a person to whom a health insurer has delegated credentialing or recredentialing authority and responsibility.

(3) “Health benefit plan” means any accident and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, plan provided by a multiple employer welfare arrangement, or plan provided by another benefit arrangement. The term “health benefit plan” does not mean accident only, credit, or disability insurance; coverage of Medicare services or federal employee health plans, pursuant to contracts with the United States government; Medicare supplemental or long-term care insurance; dental only or vision only insurance; specified disease insurance; hospital confinement indemnity coverage; limited benefit health coverage; coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law; automobile medical payment insurance; medical expense and loss of income benefits; or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(4) “Health care provider” means:

(A) An individual who is licensed, certified, or otherwise authorized to provide health care services by the District of Columbia for a practice set forth under § 3-1201.02; or

(B) An agency, organization, facility, or distinct part of any of them, licensed under subchapter I of Chapter 5 of Title 44.

(5) “Health insurer” means any person that provides one or more health benefit plans or insurance in the District of Columbia, including an insurer, a hospital and medical services corporation, a fraternal benefit society, a health maintenance organization, a multiple employer welfare arrangement, or any other person providing a plan of health insurance subject to the authority of the Commissioner.

(6) “Provider panel” means providers that contract with a health insurer to provide health care services to the enrollees under a health benefit plan of the health insurer.

(7) “Uniform credentialing form” means the form designed by the Commissioner, by regulation, for use by a health insurer or its credentialing intermediary for credentialing and re-credentialing of a health care provider for participation on a provider panel.

§ 31–3252. Application for becoming credentialed.

(a) A health insurer or its credentialing intermediary shall accept the uniform credentialing form as the sole application for a health care provider to become credentialed or recredentialed for a provider panel of the health insurer.

(b) A health insurer or its credentialing intermediary shall make the uniform credentialing form available to any health care provider that is to be credentialed or re-credentialed by the health insurer or credentialing intermediary.

§ 31–3253. Penalties.

The Commissioner may impose a penalty not to exceed $500 against any health insurer for each violation of this subchapter by the health insurer or its credentialing intermediary.

§ 31–3254. Regulations.

The Commissioner shall promulgate rules and regulations to implement the provisions of this subchapter.

§ 31–3255. Applicability.

This subchapter shall apply, 120 days after the promulgation of the final regulations pursuant to § 31-3254, to health insurers, as defined in § 31-3251(5), and any agency, organization, facility, or distinct part thereof, licensed pursuant to subchapter I of Chapter 5 of Title 44.