D.C. Mun. Regs. tit. 26, r. 26-A4704
A health carrier offering a network plan shall satisfy all the requirements contained in this section.
A health carrier shall notify the participating providers which of the covered health care services the provider will be responsible for, including any limitations or conditions on those services.
Every contract between a health carrier and a participating provider shall include a hold harmless provision. The requirement may be satisfied by including the following language, or other language approved by the Commissioner:
"[Physician/Hospital] hereby agrees that in no event, including, but not limited to, non-payment by Corporation or entity with access to this Agreement by virtue of a contract with Corporation for any reason, including a determination that the services furnished were not Medically Necessary, Corporation's insolvency, [Physician/Hospital]'s failure to submit claims within the time period specified or breach of this Agreement, will [Physician/Hospital] bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Members or persons other than Corporation for Covered Services furnished pursuant to this Agreement. This provision will not prohibit collection of applicable copayments, coinsurance or deductibles billed in accordance with the terms of Corporation's agreements with Members.
[Physician/Hospital] further agrees that this provision will survive the termination of this Agreement regardless of the cause giving rise to such termination and will be construed to be for the benefit of Members. Finally, this provision supersedes any oral or written agreement to the contrary now existing or hereafter entered into between [Physician/Hospital] and Members or persons acting on their behalf.
Any modifications, additions, or deletions to the provisions of this hold harmless clause will become effective on a date no earlier than thirty (30) days after the Commissioner has received written notice of such proposed changes."
Carriers shall file with the Commissioner the language used for hold harmless provisions as described under §4704.3 no later than thirty (30) days after the effective date of these rules.
Every contract between a health carrier and a participating provider shall set forth that, in the event of a health carrier or intermediary insolvency or other cessation of operations, the provider's obligation to deliver covered services to covered persons without balance billing will continue until the earlier of:
The contract provisions that satisfy the requirements of §§4704.2 and 4704.3 shall be construed in favor of the covered person, and shall survive the termination of the contract regardless of the reason for termination, including the insolvency of the health carrier, and shall supersede any oral or written contrary agreement between a provider and a covered person or the representative of a covered person if the contrary agreement is inconsistent with the hold harmless and continuation of covered services provisions required by §§4704.2 and 4704.3 of this section.
In no event shall a participating provider collect or attempt to collect from a covered person any money owed to the provider by the health carrier.
Health carrier selection standards for selecting and tiering (if applicable) participating providers shall be developed for providers and each health care professional specialty, if applicable. The standards shall be used in determining the selection and tiering of participating providers by the health carrier and its intermediaries.
Health carrier selection standards shall meet the requirements of the District's health care credentialing rules at 26-A DCMR §§ 4200et seq.
The health carrier selection standards may not:
Section 4704. 10 may not be construed to require a health carrier to contract with any provider willing to abide by the terms and conditions for participation established by the carrier and shall not be construed to prohibit a carrier from declining to select a provider who fails to meet legitimate criteria in the health carrier selection standards developed in compliance with this section.
A health carrier shall notify participating providers of the provider's responsibilities with respect to the health carrier's administrative policies and programs regarding, among others: payment terms; provider directory updates; utilization review; quality assessment and improvement programs; credentialing; grievance and appeals procedures; data reporting requirements; reporting requirements for timely notice of changes in practice, such as discontinuance of accepting new patients; confidentiality requirements; and any applicable District or federal programs.
A health carrier is prohibited from offering anything of value as an inducement to a provider to withhold medically necessary services, equipment, prescriptions and referrals.
A health carrier shall not prohibit a participating provider from discussing any treatment options with covered persons, irrespective of the health carrier's position on the treatment options; or from advocating on behalf of covered persons for medically necessary treatments during the utilization review, or grievance or appeals processes, or on behalf of other persons who have contracted with the carrier while enforcing any right or remedy available under applicable District or federal law.
A health carrier shall provide at least sixty (60) days written notice to a participating provider before the provider is removed from the network without cause.
The health carrier shall make a good faith effort to provide written notice of a provider's removal or withdrawal from the network, within thirty (30) days of receipt or delivery of the notice, to all covered persons who have that provider as their assigned provider.
The provisions of this chapter do not require a health carrier, its intermediaries, or the provider networks that it contracts with, to employ specific providers acting within the scope of their license or certification under District law that may meet their selection criteria; or to contract with or retain more providers acting within the scope of their license or certification under District law than are necessary to maintain a sufficient provider network under § 4702 of this chapter.
A provider contract shall not contain provisions that conflict with the provisions contained in the network plan, or the requirements of this chapter.
A health carrier shall inform a provider in a timely manner of the provider's network participation status on any health benefit plan in which the provider participates.
Where a provider is terminated without cause, a carrier shall allow a covered person receiving an active course of treatment to continue treatment with that provider until the treatment is complete, or until ninety (90) days after the discontinuation's effective date, whichever is shorter, at in-network cost-sharing rates.
If applicable, for non-emergency services, a provider contract with a facility shall include a provision regarding the written disclosure or notice to be provided to a covered person, and who shall provide such notice, at the time of authorization for services, or within ten (10) days of an appointment for in-patient or outpatient services at the facility, or at the time of a non-emergency admission at the facility, acknowledging that the facility is a participating provider of the covered person's network plan and disclosing that certain providers at the facility may not be participating providers, such as an anesthesiologist, pathologist or radiologist, but may be performing services for the covered person. The disclosure or notice shall state that the covered person may be subject to higher cost-sharing pursuant to the plan summary of benefits and coverage, including balance billing, if the covered services are performed by an out-of-network provider at a participating facility, and that information regarding how much the health plan will pay for covered services performed by out-of-network providers is available upon request. The disclosure or notice also shall inform a covered person, or their authorized representative, of the participating providers available to provide the covered services.
D.C. Mun. Regs. tit. 26, r. 26-A4704