Establishment and Maintenance of Internet Web Site — Web-Based Preadjudication Tool
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By July 1, 2010, a health insurance entity shall establish and maintain an Internet web site, which shall be accessible to health care providers with whom the health insurance entity has an express and a valid network provider agreement or contract.
Excluding inpatient claims, every health insurance entity shall make available on the Internet web site established pursuant to subsection (a) a web-based preadjudication tool to be used by a health care provider prior to the provider's submitting either a clean claim as defined in § 56-7-109 or a claim combination to the claims adjudication system utilized by the health insurance entity. The preadjudication tool shall be designed in such a manner as to be capable of:
Providing reasonably accurate information to a health care provider regarding the manner in which the health insurance entity's claim system will adjudicate claims for specific billing codes or combinations of codes; and
Providing reasonably accurate information to a health care provider regarding the allowed amount for those claims submitted pursuant to this subdivision (b)(1) based on the health care provider's fee schedule and contract with the health insurance entity for which the claim will be submitted if the claim is determined to be a clean claim.
Nothing in this subsection (b) shall be construed as requiring the preadjudication tool to reflect the effects of coverage terms and conditions unrelated to application of contract rates, fee schedules and reimbursement rules and policies, including, without limitation, eligibility for coverage, deductibles and copayments, coordination of benefits and coverage limitations and exclusions; and nothing in this subsection (b) shall be construed as requiring the preadjudication tool to respond to a provider when the data submitted by the provider is insufficient to provide the information required by subdivisions (b)(1)(A) and (B).
Health insurance entity policies affecting the information available to a provider pursuant to subsection (b) shall be easily accessible by a health care provider on the web site established by the health insurance entity pursuant to subsection (a).