Mo. Code Regs. tit. 20 § 400-14.100

Current through Register Vol. 49, No. 23, December 2, 2024

Section 20 CSR 400-14.100 - External Arbitration

PURPOSE: This rule outlines the procedures by which the department will ensure access to binding arbitration when there is a dispute related to a claim for unanticipated out-of-network care and outlines the criteria for approved arbitrators. This rule is promulgated pursuant to sections 374.045 and 376.690, RSMo.

(1) When a health carrier or a health care professional provides written notification to the director and the other party of its intent to initiate arbitration proceedings pursuant to section 376.690.2(5), RSMo, the health carrier or health care professional shall provide the following information to the director:

(A) The name and contact information for the health carrier;

(B) The name and contact information for the out-of-network health care professional;

(C) The billed amount charged by the out-of-network health care professional for the service that is the subject of the dispute;

(D) The amount of the final offer made by each party, and the date the final offer was made;

(E) An attestation affirming that the information provided by the health carrier or health care professional is true and accurate; and

(F) Any additional information requested by the director.

(2) Prior to commencing arbitration proceedings pursuant to section 376.690.2(5), RSMo, a health care professional and a health carrier must demonstrate they have completed the negotiation period described in section 376.690.2(1)-(3), RSMo.

(3) The director shall publish on the department's website (www.insurance.mo.gov) a list of entities providing arbitration services.

(4) In order to qualify as a provider of arbitration services as described in section 376.690, RSMo, an entity or arbitrator must-

(A) Be currently engaged in arbitrating disputes between health carriers and health care professionals;

(B) Adhere to procedural rules outlined by the American Arbitration Association, the American Health Lawyers Association, or another entity with similar procedural rules, as determined by the director; and

(C) Have in place policies and procedures to avoid conflicts of interest.

(5) An arbitrator or entity seeking to be included on the list published by the department may submit such a request in writing to the director, outlining its qualifications. The director has sole discretion to determine whether or not to include an arbitrator or arbitration entity on the list published by the department, and may amend or revise the list from time-to-time as he or she deems necessary.

20 CSR 400-14.100

Adopted by Missouri Register October 1, 2019/Volume 44, Number 19, effective 11/30/2019