P.R. Laws tit. 26, § 306
Any insurer or third party shall submit to the Department of Health the Puerto Rico Health Insurance Administration (ASES, Spanish acronym), any information about coverage and/or benefits paid or available to beneficiaries of the Medical Assistance Program (PAM, Spanish acronym) and any other information required. The information about eligibility and coverage shall include, but is not limited to:
(1) Name and addresses of the insured.
(2) Beneficiary identity number.
(3) Policy numbers.
(4) Group identification number.
(5) Names of covered dependents.
(6) Types of services covered under the policy.
(7) Policy effective date.
(8) Termination date for each covered individual.
The insurer or the third parties shall provide the information described in this section in electronic file format according to the specifications of the written request from the Health Department, ASES, or the Administration or its duly authorized subcontractor. The notice to the Administration shall include all the information about eligibility and available coverage from the date of the request and up to three (3) years before the request.
Any insurer or third parties that receive a written request or an electronic file regarding eligibility or the subscriber from the Department of Health, ASES, or its subcontractor shall be required to:
(a) Deliver the file to the Department of Health, ASES, and its duly authorized subcontractor within thirty (30) calendar days from the request.
(b) Supplement the initial file with monthly electronic updates of its national eligibility data to ensure that the Department of Health, the Administration, or its duly authorized subcontractor have the most current eligibility file at all times.
(c) Provide the Department of Health and ASES with Internet access to its data base.
Furthermore, insurers and third parties shall reply to the investigations conducted by the aforementioned entities and shall provide them with the information about specific individuals as required.
No fees shall be imposed to the Department of Health, the Administration, or its subcontractor for sharing electronic data as required by this section.
No insurer or third party who provides data requested by the Department of Health, ASES, or its duly authorized subcontractor may refuse to provide the same or allege that the data is confidential; however, the necessary measures shall be adopted to prevent disclosure of patient information which is not pertinent to the claim as a result of which such information is being shared. Any insurer or third party that does not comply with the provisions of this Act by failing to provide required information within a term of one hundred eighty (180) days from the date of the written request shall be subject to an administrative fine of one thousand dollars ($1,000) for each day of noncompliance with the request.
History —Ins. Code, added as § 3.050 on Dec. 21, 2010, No. 210, § 3, eff. 90 days after Dec. 21, 2010.