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 services 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 its 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 of the intermediary to ensure that providers are paid for services, or maintain member hold harmless agreements with providers.

 

History Note:        Authority G.S. 58-2-40(1); 58-2-131; 58-34-10; 58-34-15; 58-50-50; 58-50-55; 58-65-1; 58-65-25;

58-65-105; 58-65-140; 58-67-10; 58-67-20; 58-67-30; 58-67-35; 58-67-65; 58-67-100; 58-67-115;

58-67-140; 58-67-150;

Eff. October 1, 1996.