W. Va. Code R. § 114-50-3

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-50-3 - Emergency Medical Service Provider Contracts

3.1. A contract between a health maintenance organization and an emergency medical service provider must:

a. List and define duties to be assumed by the health maintenance organization and the participating provider, respectively;

b. Specify how the health maintenance organization will determine whether emergency medical services rendered by the participating provider qualify as covered emergency medical services;

c. Require the health maintenance organization to pay the participating provider in full under terms of contract for any valid claim for the covered emergency medical services rendered by the participating provider to an enrollee of the health maintenance organization, but a valid claim shall not include the amount of any deductible or copayment payable by the enrollee;

d. Require the participating provider to meet all applicable standards to which the health maintenance organization is subject;

e. Specify the service area in which the participating provider will provide emergency medical services;

f. Require the participating provider to maintain records of emergency medical services provided to an enrollee of the health maintenance organization;

g. Specify that the health maintenance organization, not its enrollee, is liable for covered emergency medical services provided to the enrollee and that the participating provider may not collect or attempt to collect from an enrollee, by action at law or otherwise, any money for covered emergency medical services rendered to the enrollee, other than a deductible or copayment payable by the enrollee;

h. Require the participating provider to give sixty (60) days advance written notice to the health maintenance organization and the commissioner before canceling the contract for any reason and specify that the health maintenance organization's nonpayment of one or more valid claims is not a valid reason for avoiding the sixty (60) day advance notice of cancellation; and

i. Specify that upon the health maintenance organization's receipt of a participating provider's sixty (60) day cancellation notice, the health maintenance organization may, in its discretion, if requested by the participating provider, terminate the contract in less than sixty (60) days if the health maintenance organization is not financially impaired or insolvent.

W. Va. Code R. § 114-50-3