TO:North Carolina Licensed HMOs
North Carolina Licensed Insurers Offering PPO Benefit Plans
FROM: Cheryl Allen-Bivens, Market Analyst
Donna Tucker, Market Analyst
Market Regulation Division
RE:NCGS 58-3-191 (“Managed care reporting and disclosure requirements.”)
The Market Regulation Division of the North Carolina Department of Insurance has posted the 2013 managed care annual filing documents for reporting data year 2012 results. Pursuant to NCGS 58-3-191, completed filings are due on or before May 1, 2013 by, 5:00p.m. EDT. These files can be downloaded from the Department’s website: ( If an Insurer believes their company should be exempt from an annual filing, a request for exemption must be received by the Department on or before the deadline of March 15, 2013 by 5:00 p.m. EDT. A request must be submitted on the Insurer’s letterhead with the reason(s) for exemption and signed by an officer of the company. The request must be sent to the attention of your company’s assigned Market Analyst, either Cheryl Allen-Bivens via or Donna Tucker via email as indicated in your Call Letter previously submitted to you via email. An exemption request is only valid for the specified data year. An exemption request must be submitted for each applicable data year.
North Carolina domestic Carriers and foreign Carriers that have and are utilizing their North Carolina domestic HMO or PPO affiliate should use the file labeled “Domestic2012InstructionsFullService.doc” or “Domestic2012InstructionsSingleService.doc”. Foreign Carriers that do not have and/or utilize a North Carolina domestic HMO or PPO affiliate must use the file labeled “Foreign2012InstructionsFullService.doc” or “Foreign2012InstructionsSingleService.doc”.
If you are a Carrier that has never submitted an Annual Filing, or if you are an existing Carrier that added/ replaced an Intermediary or added a new product line (i.e. Dental or Vision), you must complete the supplemental form labeled “InitialFilers&NewIntermediaryForm2012.doc”.
The filing must be submitted via email to and must be received no later than May 1, 2013 by 5:00 p.m. EDT. It is important to note that late, incomplete and/or non-compliant filings may be subject to a monetary penalty as outlined in NCGS 58-2-70. You must ensure that you are completing the applicable 2012document versions, and that you read the instructions for each item carefully to ensure all necessary information is provided. Feel free to contact your company’s assigned Market Analyst, Cheryl Allen-Bivens at (919) 807-6891 () or Donna Tucker, at (919) 807-6897 (), as indicated in your Call Letter previously submitted to you via email, if any you have any questions or concerns.
If the Department's Market Regulation Divisionhas performed a market conduct examination of your company within the past year, we strongly encourage you to discuss and review this filing with your company's exam coordinator, to ensure that information submitted in this filing is consistent with information furnished during the examination.
ANNUAL MANAGED CARE DATA FILING (NCGS 58-3-191)
Throughout these materials, the terms “Plan,” “Carrier” and “Insurer” refer to the licensed HMO or Insurer responsible for the filing.
1
NC Dept. of Insurance
Market Regulation Division – Foreign Carriers Single Service
January 2013
MARKET REGULATION DIVISION
C1. Annual Filing Checklist
PlanCheck-Off / ITEM # / ITEM NAME / APPLIES TO: / LOCATION / PERIOD / ITEM INSTRUCTIONS / PLAN COMMENTS
Included / C1 / Annual Filing Checklist / Plan only / C1. Annual Filing Checklist / Data Year 2012 / Submit this Checklist along with the Plan's check-offs.
Included / C2 / OverallPlan Attestation / Plan only / C2. Overall Attestation / Data Year 2012 / Submit with all requested information. Two Company officers’ signatures/dates are required.
Included
N/A / C7 / Compliance Certification: Intermediary Arrangementsincluding Pharmacy Benefit Managers / Plan only / C7. Compliance Certification: Intermediary Arrangements / Data Year 2012 / Submit one Intermediary Arrangements Compliance Certification for each Intermediary used during any part of the specified data year.
Explain if N/A:
Included
N/A / C8 / Compliance Certification: Provider Availability and Accessibility / Plan only
(Use when targets are set by the Plan.) / C8. Compliance Certification: Provider Availability and Accessibility / Data Year 2012 / Submit one Provider Availability and Accessibility Compliance Certification for the Plan and each Intermediary if the Plan set the targets for any part of the specified data year.
Explain if N/A:
Included
N/A / C9 / Compliance Certification: Delegated Provider Availability and Accessibility / Plan only
(Use when targets are set by the Intermediary or Delegated Entity.) / C9. Compliance Certification: Delegated Provider Availability and Accessibility / Data Year 2012 / Submit one Delegated Provider Availability and Accessibility Compliance Certification if the Intermediary set the targets and monitored provider availability and accessibility during any part of the specified data year.
.
List the Delegated Entity(s): / Explain if N/A:
Entity:
Entity:
Entity:
Entity:
Included
N/A / D1 / Enrollment/
Disenrollment Summary for 2012 / Plan only / Plan: Grid D1,
2012PlanDataSingleServicce.xls / As of 12/31/12
Included
N/A / D2 / Enrollment by County @ 12/31/12 / Plan only / Plan: Grid D2,
2012PlanDataSingleService.xls / As of 12/31/12
Included
N/A / D6 / Providers by County @ 12/31/12 / Plan
and/or
Intermediary(s) / Plan: Grid D6, 2012PlanDataSingleService.xls
Intermediaries: Grid D6, 2012DelegatedDataSingleService.xls / As of 12/31/12
Included
N/A / D7 / Unique Providers on Network (State-wide) / Plan
and/or
Intermediary(s) / Plan: Grid D7, 2012PlanDataSingleService.xls
Intermediaries: Grid D7, 2012DelegatedDataSingleService.xls / As of 12/31/12
Included
N/A / D8 / Providers Leaving Network During 2012, by Reason and Provider Type / Plan
and/or
Intermediary(s) / Plan: Grid D8, 2012PlanDataSingleService.xls
Intermediaries: Grid D8, 2012DelegatedDataSingleService.xls / Data Year 2012
Included
N/A / D9 / Providers Joining Network During 2012, by Provider Type / Plan
and/or
Intermediary(s) / Plan: Grid D9, 2012PlanDataSingleService.xls
Intermediaries: Grid D9, 2012DelegatedDataSingleService.xls / Data Year 2012
Included
N/A / D10 / Network Density: Plan/Intermediary Targets, by Provider Type and Geographic Area / Plan
and/or
Intermediary(s) / Plan: Grid D10, 2012PlanDataSingleService.xls
Intermediaries: Grid D10, 2012DelegatedDataSingleService.xls / Data Year 2012
Included
N/ A / D11 / Network Density: Actual Plan/Intermediary Performance, by Provider Type and Geographic Area / Plan
and/or
Intermediary(s) / Plan: Grid D11, 2012PlanDataSingleService.xls
Intermediaries: Grid D11, 2012DelegatedDataSingleService.xls / As of 12/31/12
Included
N/A / D12 / Driving Distance: Plan/Intermediary Targets, by Provider Type and Geographic Area / Plan
and/or
Intermediary(s) / Plan: Grid D12, 2012PlanDataSingleService.xls
Intermediaries: Grid D12, 2012DelegatedDataSingleService.xls / Data Year 2012
Included
N/A / D13 / Driving Distance: Actual Plan/Intermediary Performance, by Provider Type and Geographic Area / Plan
and/or
Intermediary(s) / Plan: Grid D13, 2012PlanDataSingleService.xls
Intermediaries: Grid D13, 2012DelegatedDataSingleService.xls / As of 12/31/12
Included
N/A / D14 / Appointment Wait Times: Plan/Intermediary Targets, by Provider Type and Appointment Type / Plan
and/or
Intermediary(s) / Plan: Grid D14, 2012PlanDataSingleService.xls
Intermediaries: Grid D14, 2012DelegatedDataSingleService.xls / Data Year 2012
Included
N/A / D15 / Appointment Wait Times: Actual Plan/Intermediary Performance, by Provider Type and Appointment Type / Plan
and/or
Intermediary(s) / Plan: Grid D15, 2012PlanDataSingleService.xls
Intermediaries: Grid D15, 2012DelegatedDataSingleService.xls / Data Year 2012
Included
N/A / D16 / Percentage of Providers Under Each Compensation Model, by Provider Type / Plan
and/or
Intermediary(s) / Plan: Grid D16, 2012PlanDataSingleService.xls
Intermediaries: Grid D16, 2012DelegatedDataSingleService.xls / As of 12/31/12
Included
N/A / D17 / Range of Withholds and Bonuses, by Compensation Model / Plan
and/or
Intermediary(s) / Plan: Grid D17, 2012PlanDataSingleService.xls
Intermediaries: Grid D17, 2012DelegatedDataSingleService.xls / As of 12/31/12 / N/A if the compensation model is fee-for-service without withhold or bonus.
Included
N/A / D18 / List of Plan’s Delegated Entities and Intermediaries / Plan / Plan: Grid D18, 2012PlanDataSingleService.xls / Data Year 2012 / .
Included
N/A / N/A / Outstanding issues from the previous data year being addressed and any requested information being submitted / Plan
If previous filing was closed other than “Accepted”. / N/A / N/A / Refer to the Department’s closure letter with the attachment of the final findings from the previous data year.
Included
N/A / N/A / Supplemental Checklist / New Filers or Existing Filers who added or replaced an Intermediary or added a new product line / InitialFilers&NewIntermediaryForm2012 / Data Year
2012 / Submit one form for each new Initial Operations Filing or new/replacing Intermediary Filing.
1
NC Dept. of Insurance
Market Regulation Division – Foreign Carriers Single Service
January 2013
MARKET REGULATION DIVISION
C2. Overall Attestation
(Required From All Plans Submitting a Filing.Plans that are under common ownership must submit a separate executed Attestation for each company.)
We hereby attest that we have reviewed the entire Annual Filing, and that the information being submitted for the period of January 1, 2012 through December 31, 2012 is true and complete.
The filing must be submitted electronically to the Department‘s mailbox at on or before the deadline of May 1,2013 by 5 pm EDT, or the next business day if May 1st falls on a Saturday, Sunday or holiday. It is important to note that late, incomplete and/or non-compliant filings may be subject to a monetary penalty as outlined in NCGS 58-2-70.
Late filings will require a written explanation on the company’s letterhead signed/dated by the Company’s President at time of submission.
IMPORTANT NOTE: If the previous data year’s filing was closed as “Accepted with Issues” or “Non-compliant”, the Insurer must make sure to address the issues outlined in the Department’s closure letter and submit any requested information. Unresolved/Unanswered issues, failing to implement corrective action or compliance issues impacting North Carolina insureds may result in a market inquiry, market conduct examination and/or administrative penalty.
Name(Printed Name)Name(Printed Name)
Title (Company Officer)Title (Company Officer)
SignatureDateSignatureDate
Company Name
PRIMARY CONTACT INFORMATION
Name of Person Submitting the Filing (Printed)Title
Street AddressCityStateZip
Mailing AddressCityStateZip
( )( )
Direct Phone Number Toll Free Phone Number including extension
Fax Number
E-Mail Address
PLEASE PROVIDE A BACKUP CONTACT, OR IF THE PERSON SUBMITTING THE FILING IS A CONSULTANT, A COMPANY CONTACT MUST BE PROVIDED.
Name of Person (Printed)Title
Street AddressCityStateZip
Mailing AddressCityStateZip
( )( )
Direct Phone Number Toll Free Phone Number including extension
Fax Number
E-Mail Address
1
NC Dept. of Insurance
Market Regulation Division – Foreign Carriers Single Service
January 2013
MARKET REGULATION DIVISION
C7. Compliance Certification: Intermediary Arrangements
Submit one Certification for each subcontracted Intermediary.
Pursuant to 11 NCAC 20.0204 (“Carrier and Intermediary Contracts”),
(“Carrier”), duly licensed and authorized to do business in the State of North Carolina, hereby provides notification that it has entered into a subcontractual relationship with (“Intermediary”). Carrier certifies to the Commissioner of the North Carolina Department of Insurance that the Carrier’s contract with the Intermediary, and the Intermediary’s own program, are fully compliant with all of the Regulations listed and referenced below.
Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.
I.Applicable Regulations
11 NCAC 20.0204 Carrier and Intermediary Contracts.
(a) If a Carrier contracts with an intermediary for the provision of a network to deliver health care services, the Carrier shall file with the Division for prior approval its form contract with the intermediary.
The filing shall be accompanied by a certification from the Carrier that the intermediary will, by the terms of the contract, be required to comply with all statutory and regulatory requirements which apply to the functions delegated. The certification shall also state that the Carrier shall monitor such compliance.
(b) A Carrier's contract form with the intermediary shall state that:
(1) All provider contracts used by the intermediary shall comply with, and include applicable provisions of 11 NCAC 20.0202.
(2) The network Carrier retains its legal responsibility to monitor and oversee the offering of services to its members and financial responsibility to its members.
(3) The intermediary may not subcontract for its service without the Carrier's written permission.
(4) The Carrier may approve or disapprove participation of individual providers contracting with the intermediary for inclusion in or removal from the Carrier's own network plan.
(5) The Carrier shall retain copies or the intermediary shall make available for review by the Department all provider contracts and subcontracts held by the intermediary.
(6) If the intermediary organization assumes risk from the Carrier or pays its providers on a risk basis or is responsible for claims payment to it providers:
(A) The Carrier shall receive documentation of utilization and claims payment and maintain accounting systems and records necessary to support the arrangement.
(B) The Carrier shall arrange for financial protection of itself and its members through such approaches as member hold harmless language, retention of signatory control of the funds to be disbursed or financial reporting requirements.
(C) To the extent provided by law, the Department shall have access to the books, records, and financial information to examine activities performed by the intermediary on behalf of the Carrier. Such books and records shall be maintained in the State of North Carolina.
(7) The intermediary shall comply with all applicable statutory and regulatory requirements that apply to the functions delegated by the Carrier and assumed by the intermediary.
(c) If a Carrier contracts with an intermediary to provide health care services and pays that intermediary directly for the services provided, the Carrier shall either monitor the financial condition ofthe intermediary to ensure that providers are paid for services, or maintain member hold harmless agreements with providers.
11 NCAC 20.0202Contract Provisions.
All contract forms that are created or amended on or after the effective date of this Section, and all contract forms that are executed later than six (6) months after the effective date of this Section, shall contain provisions addressing the following:
(1) Whether the contract and any attached or incorporated amendments, exhibits, or appendices constitute the entire contract between the parties.
(2) Definitions of technical insurance or managed care terms used in the contract, and whether those definitions reference other documents distributed to providers and are consistent with definitions included in the evidence of coverage issued in conjunction with the network plan.
(3) An indication of the term of the contract.
(4) Any requirements for written notice of termination and each party's grounds for termination.
(5) The provider's continuing obligations after termination of the provider contract or in the case of the Carrier or intermediary insolvency. The obligations shall address:
(a) Transition of administrative duties and records.
(b) Continuation of care, when inpatient care is on-going. If the Carrier provides or arranges for the delivery of health care services on a prepaid basis, inpatient care shall be continued until the patient is ready for discharge.
(6) The provider's obligation to maintain licensure, accreditation, and credentials sufficient to meet the Carrier's credential verification program requirements and to notify the Carrier of subsequent changes in status of any information relating to the provider's professional credentials.
(7) The provider's obligation to maintain professional liability insurance coverage in an amount acceptable to the Carrier and notify the Carrier of subsequent changes in status of professional liability insurance on a timely basis.
(8) With respect to member billing:
(a) If the Carrier provides or arranges for the delivery of health care services on a prepaid basis under G.S. 58, Article 67, the provider shall not bill any network plan member for covered services, except for specified coinsurance, copayments, and applicable deductibles. This provision shall not prohibit a provider and member from agreeing to continue noncovered services at the member’sown expense, as long as the provider has notified the member in advance that the Carrier may not cover or continue to cover specific services and the member chooses to receive the service.
(b) Any provider's responsibility to collect applicable member deductibles, copayments, coinsurance, and fees for noncovered services shall be specified.
(9) Any provider's obligation to arrange for call coverage or other back-up to provide service in accordance with the Carrier's standards for provider accessibility.
(10) The Carrier's obligation to provide a mechanism that allows providers to verify member eligibility, based on current information held by the Carrier, before rendering health care services. Mutuallyagreeable provision may be made for cases where incorrect or retroactive information was submitted by employer groups.
(11) Provider requirements regarding patients' records. The provider shall:
(a) Maintain confidentiality of enrollee medical records and personal information as required by
G.S. 58, Article 39 and other health records as required by law.
(b) Maintain adequate medical and other health records according to industry and Carrier standards.
(c) Make copies of such records available to the Carrier and Department in conjunction with its regulation of the Carrier.
(12) The provider's obligation to cooperate with members in member grievance procedures.
(13) A provision that the provider shall not discriminate against members on the basis of race, color, national origin, gender, age, religion, marital status, health status, or health insurance coverage.
(14) Provider payment that describes the methodology to be used as a basis for payment to the provider (for example, Medicare DRG reimbursement, discounted fee for service, withhold arrangement, HMO provider capitation, or capitation with bonus).
(15) The Carrier's obligations to provide data and information to the provider, such as:
(a)Performance feedback reports or information to the provider, if compensation is related to efficiency criteria.
(b)Information on benefit exclusions; administrative and utilization management requirements; credential verification programs; quality assessment programs; and provider sanction policies. Notification of changes in these requirements shall also be provided by the Carrier, allowing providers time to comply with such changes.
(16) The provider's obligations to comply with the Carrier's utilization management programs, credential verification programs, quality management programs, and provider sanctions programs with the provision that none of these shall override the professional or ethical responsibility of the provider or interfere with the provider's ability to provide information or assistance to their patients.
(17) The provider's authorization and the Carrier's obligation to include the name of the provider or the provider group in the provider directory distributed to its members.