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- Alaska Statutes.
- Title 21. Insurance
- Chapter 7. Regulation of Managed Care Insurance Plans
- Section 20. Required Contract Provisions For Managed Care Plans.
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. Patient and Health Care Provider Protection.
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. Choice of Health Care Provider.
AS 21.07.020. Required Contract Provisions For Managed Care Plans.
A managed care plan must contain
- (1) a provision that preauthorization for a covered medical procedure on the basis of medical necessity may not be
retroactively denied unless the preauthorization is based on materially incomplete or inaccurate information provided
by or on behalf of the provider;
- (2) a provision for emergency room services if any coverage is provided for treatment of a medical emergency;
- (3) a provision that covered medical care services be reasonably available in the community in which a covered person
resides or that, if referrals are required by the plan, adequate referrals outside the community be available if the
medical care service is not available in the community;
- (4) a provision that any utilization review decision
- (A) must be made within 72 hours after receiving the request for preapproval for nonemergency situations; for emergency
situations, utilization review decisions for care following emergency services must be made as soon as is practicable
but in any event not later than 24 hours after receiving the request for preapproval or for coverage determination; and
- (B) to deny, reduce, or terminate a health care benefit or to deny payment for a medical care service because that service
is not medically necessary shall be made by an employee or agent of the managed care entity who is a licensed health
- (5) a provision that provides for an internal appeal mechanism for a covered person who disagrees with a utilization
review decision made by a managed care entity; except as provided under (6) of this section, this appeal mechanism must
provide for a written decision
- (A) from the managed care entity within 18 working days after the date written notice of an appeal is received; and
- (B) on the appeal by an employee or agent of the managed care entity who holds the same professional license as the health
care provider who is treating the covered person;
- (6) a provision that provides for an internal appeal mechanism for a covered person who disagrees with a utilization
review decision made by a managed care entity in any case in which delay would, in the written opinion of the treating
provider, jeopardize the covered person's life or materially jeopardize the covered person's health; the managed care
- (A) decide an appeal described in this paragraph within 72 hours after receiving the appeal; and
- (B) provide for a written decision on the appeal by an employee or agent of the managed care entity who holds the same
professional license as the health care provider who is treating the covered person;
- (7) a provision that discloses the existence of the right to an external appeal of a utilization review decision made by a
managed care entity; the external appeal shall be as conducted in accordance with AS 21.07.050;
- (8) a provision that discloses covered benefits, optional supplemental benefits, and benefits relating to and restrictions
on nonparticipating provider services;
- (9) a provision that describes the preapproval requirements and whether clinical trials or experimental or investigational
treatment are covered;
- (10) a provision describing a mechanism for assignment of benefits for health care providers and payment of benefits;
- (11) a provision describing availability of prescription medications or a formulary guide, and whether medications not
listed are excluded; if a formulary guide is made available, the guide must be updated annually; and
- (12) a provision describing available translation or interpreter services, including audiotape or braille information.
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