TITLE XXXVII
INSURANCE
Chapter 420-J
MANAGED CARE LAW
Section 420-J:1
420-J:1 Purpose and Intent. –
The purpose and intent of this chapter is to provide standards for certain fundamental operations of licensed entities providing health insurance through a managed care system of health care delivery and reimbursement. The establishment of these standards will ensure regulatory and quality consistency among the several and various licensees offering managed care type benefit plans and will enable consumers to make informed decisions in their relationships with managed care insurers. This chapter is intended to apply only to those insurers offering managed care plans. It is not intended to apply to traditional indemnity systems of reimbursement and fee-for-service forms of health care expense coverage. Health insurers which do not significantly limit covered persons' choices of providers shall not be subject to this chapter.
Source. 1997, 345:1, eff. Jan. 1, 1998.
Section 420-J:2
420-J:2 Applicability and Scope. –
This chapter shall apply to all health carriers offering a managed care plan in this state.
Source. 1997, 345:1, eff. Jan. 1, 1998.
Section 420-J:3
420-J:3 Definitions. –
In this chapter:
I. "Adverse determination" means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay or other health care service has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service is therefore denied, reduced, or terminated.
II. "Ambulatory review" means utilization review of health care services performed or provided in an outpatient setting.
III. "Appeals procedure" means a formal process whereby a covered person, a representative of a covered person, attending physician, facility or health care provider can contest an adverse determination rendered by the health carrier or its designee utilization review organization, which results in the denial, reduction or termination of a requested health care service.
III-a. "Authorized representative" means a person to whom a covered person has given consent to represent the covered person in an external review. Authorized representative may include the covered person's treating provider.
IV. "Case management" means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions.
V. "Certification" means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness.
V-a. "Claim denial" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.
V-b. "Claim involving urgent care" means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations:
(a) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
(b) In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
V-c. "Claimant's representative" shall mean an individual authorized by a claimant in writing to pursue a claim or appeal on the claimant's behalf.
VI. "Clinical peer" means a physician or other health care professional who holds a non-restricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review. A "clinical peer" includes a health care professional who has demonstrable expertise to review a case, whether or not the reviewing professional is in the same or a similar specialty as the health care professional who made the initial decision.
VII. "Clinical review criteria" means the written policies, screening procedures, decision abstracts, clinical protocols, practice guidelines, medical protocols, and any other written decision-making standards used by a health carrier or utilization review entity to determine the medical necessity and appropriateness of health care services.
VIII. "Commissioner" means the insurance commissioner.
IX. "Concurrent hospital review" means utilization review conducted during a patient's inpatient stay or course of treatment.
X. "Consumer" means someone in the general public who may or may not be a covered person or a purchaser of health care including employers.
X-a. "Contracted pharmacy" or "pharmacy" means a pharmacy participating in the network of a pharmacy benefit manager through a direct contract or through a contract with a pharmacy services administration organization or group purchasing organization.
XI. "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan.
XII. "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.
XIII. "Credentialing verification" is the process of obtaining and verifying information about a health care professional, and evaluating that health care professional, when that health care professional applies to become a participating provider in a managed care plan offered by a health carrier.
XIV. "Discharge planning" means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility.
XIV-a. "Drug product reimbursement" means the amount paid by a carrier or pharmacy benefit manager to a contracted pharmacy or pharmacist for the cost of the drug dispensed to a patient and does not include a dispensing or professional fee.
XV. "Emergency medical condition" means "emergency medical condition" as defined in 42 U.S.C. section 300gg-111(a)(3)(B).
XVI. "Emergency services" means health care services, including mental health and substance use disorder treatment services, that meet the definition of "emergency services" in 42 U.S.C. section 300gg-111(a)(3)(C).
XVI-a. "Episode of care" means the period of time during which all of the health care services that are needed to care for a patient's clinical condition or to complete a procedure are delivered.
XVII. "Facility" means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.
XVIII. "Grievance" means a written complaint submitted by or on behalf of a covered person regarding the:
(a) Availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;
(b) Claims payment, handling, or reimbursement for health care services; or
(c) Matters pertaining to the contractual relationship between a covered person and a health carrier.
XIX. "Health benefit plan" means a policy, contract certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
XX. "Health care professional" means a physician or other health care practitioner licensed, accredited, or certified to perform specified health services consistent with state law.
XXI. "Health care provider" or "provider" means a health care professional or facility.
XXII. "Health care services" or "health services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.
XXIII. "Health carrier" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurance company, a health maintenance organization, a health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services.
XXIII-a. "Independent review organization" means an entity that employs or contracts with clinical peers to conduct independent external reviews of health carrier determinations.
XXIV. "Intermediary" means a person authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network.
XXV. "Managed care plan" means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by the health carrier.
XXV-a. "Medical director" means a physician licensed under RSA 329 and employed by a health carrier or medical utilization review entity who is responsible for the utilization review techniques and methods of the health carrier or medical utilization review entity and their administration and implementation.
XXV-b. "Medical necessity" means health care services or products provided to an enrollee for the purpose of preventing, stabilizing, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease in a manner that is:
(a) Consistent with generally accepted standards of medical practice;
(b) Clinically appropriate in terms of type, frequency, extent, site, and duration;
(c) Demonstrated through scientific evidence to be effective in improving health outcomes;
(d) Representative of "best practices" in the medical profession; and
(e) Not primarily for the convenience of the enrollee or physician or other health care provider.
XXVI. "Network" means the group of participating providers providing services to a managed care plan.
XXVI-a. "Nonparticipating emergency facility" means an emergency department of a hospital or an independent freestanding emergency department as defined in 42 U.S.C. section 300gg-111(a)(3)(D) that does not have a contractual relationship directly or indirectly with a health carrier.
XXVI-b. "Nonparticipating provider" means any health care provider, excluding ground and air ambulance service providers, who is acting within the scope of practice of that provider's license or certification under applicable state law and who does not have a contractual relationship directly or indirectly with a health carrier.
XXVII. "Participating provider or facility" means a provider or facility that, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier.
XXVIII. "Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing.
XXVIII-a. "Pharmacy benefits manager" means "pharmacy benefits manager" as defined in RSA 402-N:1, VIII.
XXVIII-b. "Prior authorization" means the approval from a health carrier or utilization review entity that may be required before a particular health care service, item, or prescription drug is received by the covered person in order for that service, item or prescription drug to be covered under the covered person's plan.
XXVIII-c. "Prior authorization determination" means a determination by a health carrier or a utilization review entity that a health care service, item or prescription drug has been reviewed pursuant to a request for prior authorization and, based on the information provided, satisfies or does not satisfy the health carrier's or the utilization review entity's requirements for coverage.
XXVIII-aa. "Post-service claim" means any claim for a health benefit to which the terms of the plan do not condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining the medical care or disability benefit. "Post-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.
XXIX. "Prospective review" means utilization review conducted prior to an admission or a course of treatment.
XXIX-a. "Qualifying payment amount" means "qualifying payment amount" as defined in 42 U.S.C. section 300gg-111(3)(E).
XXX. "Quality assessment" means the measurement and evaluation of the quality and outcomes of medical care provided to individuals, groups, or populations.
XXXI. "Quality improvement" means the effort to improve the processes and outcomes related to the provision of health care services within the health benefit plan.
XXXII. "Retrospective review" means a review of medical necessity conducted after services have been provided to a patient, but does not include a claims settlement process including an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, adjudication for payment, or whether a service is a covered benefit under the plan.
XXXIII. "Second opinion" means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health service to assess the clinical necessity and appropriateness of the initial proposed health service.
XXXIV. "Utilization review" means a set of formal techniques designed to monitor the use of or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services procedures, providers, or facilities. Techniques and methods may include, but are not limited to ambulatory care review, case management, concurrent hospital review, discharge planning, pre-hospital admission certification, pre-inpatient service eligibility certification, prospective review, prior authorization, second opinion, or retrospective review.
XXXIV-a. "Urgent care" means a medical or behavioral health care service available to a covered person which, if delayed:
(a) Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or
(b) In the opinion of a provider with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the available health care service.
XXXV. "Utilization review entity" means an entity described in RSA 420-E:2 as being subject to licensure pursuant to RSA 420-E.
Source. 1997, 345:1; 345:10. 2000, 18:4, 11, 12. 2001, 207:10, 11, 14. 2003, 175:8. 2007, 33:1. 2014, 150:1, eff. Aug. 15, 2014. 2016, 177:1, 2, eff. Jan. 1, 2017. 2018, 356:6, 7, eff. July 1, 2018. 2019, 320:4, eff. Jan. 1, 2020. 2024, 143:3-7, eff. Jan. 1, 2025; 172:1-4, eff. Jan. 1, 2025.
Section 420-J:3-a
420-J:3-a Access to Enhanced 911 System. –
I. No health benefit plan issued or renewed after July 7, 2000 shall contain any provision which establishes or promotes an emergency medical response or transportation system that encourages or directs access by a covered person in competition with or in substitution of the state enhanced 911 system or other state, county, or local government emergency medical services system.
II. Notwithstanding paragraph I, a health carrier subject to this chapter may use transportation outside the enhanced 911 or other government emergency medical services system for services that are not in response to an emergency medical condition, as defined in RSA 420-J:3, XV.
III. No health benefit plan issued or renewed after July 7, 2000 shall contain any provision requiring a covered person to obtain prior authorization before accessing the enhanced 911 system or other state, county, or local government emergency medical services system for response and/or transportation for emergency services, as defined in RSA 420-J:3, XVI.
IV. No person who issues a health benefit plan subject to this chapter shall use false or misleading language in its enrollment sales materials or in any other materials provided to covered persons to discourage or prohibit covered persons from accessing the enhanced 911 system for response and/or transportation for emergency services.
Source. 2000, 104:2, eff. July 7, 2000.
Section 420-J:3-b
420-J:3-b Pre-certification Requirement. –
In the event that a person is covered by more than one plan that requires pre-certification, the member shall obtain pre-certification from the primary plan. Although the member shall not be required to obtain pre-certification from the secondary plan, the secondary plan shall not be required to treat such services as covered services if the services do not meet its certification criteria. The secondary plan shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan.
Source. 2007, 289:26, eff. Jan. 1, 2008.
Section 420-J:4
420-J:4 Credentialing Verification Procedures. –
I. A health carrier shall:
(a) Establish written policies and procedures for credentialing verification of all health care professionals with whom the health carrier contracts and apply these standards consistently.
(b) Verify the credentials of a health care professional. Prior to completion of credentialing verification the health carrier shall:
(1) Allow a health care provider who, at the time of submission of a clean and complete application, has a valid license from the respective state licensing board and has been credentialed by the hospital, if appropriate, to deliver health care services to covered persons when covering on-call for another health care provider who is credentialed by the carrier.
(2) Allow a health care provider to deliver health care services to covered persons when that health care provider has a valid license from the respective state licensing board and has been credentialed by the hospital, if appropriate, and who at the time of submission of a clean and complete application is credentialed by the health carrier in another state or is in the health carrier's New Hampshire network based on employment with a particular health care entity. When a health care provider relocates or opens an additional office and the carrier requires a site visit, documentation of the new site evaluation shall be required as part of the credentialing process. The medical director of the health carrier or other designated health care professional shall have responsibility for, and shall participate in, health care professional credentialing verification.
(c) Establish a credentialing verification committee consisting of licensed physicians and other health care professionals to review credentialing verification information and supporting documents and make decisions regarding credentialing verification.
(d) Make available for review by the applying health care professional upon written request all application and credentialing verification policies and procedures.
(e) Retain records and documents relating to a health care professional's credentialing verification process for 7 years.
(f) Keep confidential all information obtained in the credentialing verification process, except as otherwise provided by law.
(g) Notify a health care provider that a submitted credentialing application is incomplete, not later than 15 business days after receiving the credentialing application.
(h) Act upon and finalize the credentialing process within 30 calendar days of receipt of a clean and complete application for primary care physicians and mental health providers and within 45 days of receipt of a clean and complete application for specialists. In this section, "clean and complete" means an application signed and appropriately dated by the health care provider, that includes all of the applicable information required in paragraph II and any affirmative responses on questions related to quality and clinical competence shall contain explanations satisfactory to the carrier.
(i) An applicant's rights under this section and under RSA 420-J:8-c shall terminate upon denial of the credentialing application by the health carrier or if the applicant decides not to contract with the health carrier.
II. A health carrier shall obtain verification of at least the following information about the applicant:
(a) Graduation from health care professional school.
(b) Completion of post graduate training (if applicable).
(c) The health care professional's license history in this and all other states.
(d) The health care professional's malpractice history.
(e) The health care professional's practice history.
(f) Current license, certificate of authority, or registration to practice a health care profession in New Hampshire.
(g) Current level of professional liability coverage (if applicable).
(h) Status of hospital privileges (if applicable).
(i) Specialty board certification status (if applicable).
(j) Current Drug Enforcement Agency (DEA) registration certificate (if applicable).
III. A health carrier shall thereafter obtain, at least every 3 years, verification of a participating provider's:
(a) Current license, certificate of authority or registration to practice a health care profession in New Hampshire.
(b) Current level of professional liability coverage (if applicable).
(c) Status of hospital privileges (if applicable).
(d) Current DEA registration certificate (if applicable).
(e) Specialty board certification status (if applicable).
IV. A health carrier shall require all participating providers to notify the health carrier of changes in the status of any items listed in this section at any time, and shall identify for participating providers the individual or department to whom they should report such changes. The carrier shall act upon the change in status request within 30 days of receipt of the request or shall notify the provider of the reason for delay or inability to act.
V. Whenever a health carrier contracts to have another entity perform the credential verification functions required by this section or applicable rules, the commissioner shall hold the health carrier responsible for monitoring the activities of the entity with which it contracts and for ensuring that the requirements of this section and applicable rules are met.
VI. Nothing in this section shall be construed to require a health carrier to select a health care professional as a participating provider solely because the health care professional meets the health carrier's credentialing verification standards, or to prevent a health carrier from utilizing separate or additional criteria in selecting the health care professionals with whom it contracts.
VII. The commissioner shall accept and record complaints for health care providers regarding a health carrier's alleged non-compliance with the provisions of this section and may take such regulatory action as deemed necessary in response to complaints received.
Source. 1997, 345:1. 2002, 207:41. 2007, 98:1, eff. Aug. 10, 2007. 2023, 98:1, 2, eff. Aug. 19, 2023. 2025, 32:1, eff. Jan. 1, 2026.
Section 420-J:4-a
420-J:4-a Facility Credentialing. –
I. Health carriers shall credential qualified entities administering community mental health programs as defined under RSA 135-C:7, entities administering community substance use disorder treatment programs as defined under RSA 172:2-c, and community health centers as facilities when paneling and enrolling participating providers, consistent with health carriers' facility credentialing standards and practices, unless the entity requests professional level credentialing. Health carriers shall not be required to credential entities who do not meet the health carriers' facility credentialing eligibility standards. If an entity disagrees with the outcome of a health carrier's application of its facility credentialing standards and practices, the entity may request a formal hearing and review of the carrier's decision by the New Hampshire insurance department pursuant to RSA 400-A:17 and/or file a complaint with the New Hampshire insurance department's health care provider complaint process.
II. Nothing in this section shall be construed to require a health carrier to select or enroll a specific facility as a participating provider.
Source. 2021, 183:9, eff. Sept. 9, 2021.
Section 420-J:5
420-J:5 Grievance Procedures. –
Every carrier or other licensed entity shall establish and shall maintain a written procedure by which a claimant or a representative of the claimant, shall have a reasonable opportunity to appeal a claim denial to the carrier or other licensed entity, and under which there shall be a full and fair review of the claim denial. The written procedure filed with the insurance department shall include all forms used to process an appeal.
I. Full and fair review shall require that:
(a) The persons reviewing the grievance shall not be the same person or persons making the initial determination, and shall not be subordinate to or the supervisor of the person making the initial determination;
(b) For medical necessity appeals, the health carrier conducting utilization review directly, or indirectly through a contracted utilization review entity, shall ensure that all reviews are conducted by or in consultation with a health care professional. The health care professional shall:
(1) Be a practitioner in the same or similar specialty who typically treats the medical condition, performs the procedure, or provides the treatment at issue in the appeal. A practitioner is considered of the same specialty if he or she has similar credentials and licensure as those who typically treat the condition or health problem in question in the appeal. A practitioner is considered of a similar specialty if he or she has experience treating the same problems as those in question in the appeal, in addition to expertise treating similar complications of those problems; and
(2) Consider all known clinical aspects of the health care service under review, including, but not limited to, a review of all pertinent medical records and medical literature provided to the health carrier or the contracted utilization review entity by the covered person's health care provider and any relevant records provided to the health carrier or the contracted utilization review entity by a health care facility.
(c) The claimant shall have at least 180 days following receipt of a notification of a claim denial to appeal;
(d) The claimant shall have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those documents or materials were considered in making the initial determination;
(e) The claimant shall be provided upon request, and without charge, reasonable access to, and copies of all documents, records, and other information relevant to or considered in making the initial adverse claim determination; and
(f) The review shall be a de novo proceeding and shall consider all information, documents, or other material submitted in connection with the appeal without regard to whether the information was considered in making the denial.
II. In the appeal of a claim denial that is based in whole or in part on a medical judgment:
(a) The review shall be conducted by or in consultation with a health care professional in the same or similar specialty who typically treats the medical condition, performs the procedure, or provides the treatment at issue in the appeal. A practitioner is considered of the same specialty if he or she has similar credentials and licensure as those who typically treat the condition or health problem in question in the appeal. A practitioner is considered of a similar specialty if he or she has experience treating the same problems as those in question in the appeal, in addition to expertise treating similar complications of those problems;
(b) The titles and qualifying credentials of the person conducting the review shall be included in the decision; and
(c) The identity and qualifications of any medical or vocational expert whose advice was considered, without regard to whether it was relied upon in making the initial claim denial, shall be made available to the claimant upon request.
III. In the appeal of a claim for urgent care, a claim involving a matter that would seriously jeopardize the life or health of a covered person or would jeopardize the covered person's ability to regain maximum function, or a claim concerning an admission, availability of care, continued stay or health care service for a person who has received emergency services, but who has not been discharged from a facility, an expedited appeal process shall be made available which shall provide for:
(a) The submission of information by the claimant to the carrier by telephone, facsimile, or other expeditious method; and
(b) The determination of the appeal not more than 72 hours after the submission of the request for appeal.
IV. Timing and Notification for Determination on Appeal
(a) In the case of nonexpedited appeal of a prior authorization determination or post-service claim, the determination on appeal shall be made within a reasonable time appropriate to the medical circumstances, but in no event more than 30 days after receipt by the carrier or other licensed entity of the claimant's appeal.
(b) In the case of an expedited appeal related to an urgent care claim, a carrier or other entity shall make a decision and notify the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the appeal is filed. If the expedited review involves ongoing urgent care services, the service shall be continued without liability to the covered person until the covered person has been notified of the determination. A carrier or other licensed entity shall provide written confirmation of its decision concerning an expedited review within 2 business days of providing notification of that decision, if the initial notification was not in writing.
(c) The period of time within which a decision shall be rendered on appeal shall begin to run at the time the appeal is filed in accordance with the appeal procedures of the carrier or other licensed entity, without regard to whether all the information necessary to make a determination on appeal is contained in the filing. In the event the claimant fails to submit information necessary to decide the appeal, the period for making the determination on appeal shall be tolled from the date the claimant is notified in writing of precisely what is required until the date the claimant responds to the request. The carrier or other licensed entity shall provide notification of incompleteness as soon as possible; but in no event more than 24 hours after the filing of the appeal in appeals involving urgent care. In the event that the claimant fails, within a 45-day period from the date of notification, to provide sufficient information, the carrier may deny the appeal on the basis of incompleteness. The appeal may be reopened upon receipt of the required information.
V. Manner and Content of Notification of Determination on Appeal. The carrier or other licensed entity shall provide a claimant with a written determination of the appeal.
(a) Where a decision is made to uphold, in whole or in part, the denial of benefits, the written determination of appeal shall include:
(1) The specific reason or reasons for the determination, including reference to the specific provision, rule, protocol, or guideline on which the determination is based;
(2) A statement that the rule, protocol, or guideline governing the appeal will be provided without charge to the claimant upon request;
(3) A statement describing all other dispute resolution options available to the claimant, including, but not limited to other options for internal review and options for external review and options for bringing a legal action;
(4) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits;
(5) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the claim denial, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the claim denial and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the claimant upon request;
(6) If the claim denial is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the denial, applying the terms of the plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request;
(7) If the appeal involves an adverse determination, a copy of the notice of the right to external review that includes the specific requirements for filing an external review; and
(8) A statement describing the claimant's right to contact the insurance commissioner's office for assistance which shall include the toll-free telephone number and address of the commissioner.
(b) A carrier or other licensed entity that offers group health plans, employee benefit plans, or disability plans shall file annually with the commissioner, as part of its annual report required by RSA 420-J:5, V(f), a certificate of compliance stating that the carrier or other licensed entity has established and maintained, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this chapter. Material modifications to the procedure shall be filed with the commissioner prior to becoming effective.
(c) A carrier or other licensed entity that offers group health plans, employee benefit plans, or disability plans shall maintain written records documenting all grievances and appeals received during a calendar year, a general description of the reason for the appeal or grievance, the name of the claimant, the dates of the appeal or grievance and the date of resolution.
(d) A carrier or other licensed entity that offers group health plans, employee benefit plans, or disability plans shall provide to consumers:
(1) A description of the internal grievance procedure required under RSA 420-J:5 for claim denials and other matters and a description of the process for obtaining external review under RSA 420-J:5-a-RSA 420-J:5-e. These descriptions shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons.
(2) A statement of a covered person's right to contact the commissioner's office for assistance at any time. The statement shall include the toll-free telephone number and address of the commissioner.
(3) A statement that the carrier or other licensed entity will provide assistance in preparing an appeal of an adverse benefit determination, and a toll-free telephone number to contact the carrier or other licensed entity.
(e)(1) If a carrier or other licensed entity provides 2 mandatory levels of appeal, the first level shall be completed within 15 days and the second level completed within the 30-day time period beginning from the initial date of filing the appeal or grievance. If a carrier or other licensed entity provides a single mandatory level of appeal, the single mandatory level shall be completed within the 30-day time period beginning from the initial date of filing the appeal. With respect to a mandatory second level of appeal involving a claim for continuation of services or urgent care, the carrier or other licensed entity shall make a decision and notify the claimant within 72 hours after the mandatory second level appeal is filed. For appeals involving post-service claims, the carrier shall make a decision and notify the claimant within 60 days of the date the completed appeal was filed.
(2) Subparagraph (e)(1) shall not prohibit a carrier or other licensed carrier from offering additional voluntary levels of appeal in addition to any mandatory levels of appeal offered, provided that:
(A) The claimant may elect to pursue any additional level of appeal under this subparagraph voluntarily;
(B) A carrier may not assert failure to exhaust administrative remedies where a claimant elects to pursue a claim through other venues rather than through the voluntary level of appeal;
(C) Any statute of limitations or time limits to pursue other remedies shall be tolled during the voluntary appeals process;
(D) Voluntary levels of appeal are available only after a claimant has completed required mandatory levels of appeal required under the plan or by regulation;
(E) The carrier provides a claimant with sufficient information to make an informed decision whether to submit the claim through any voluntary appeals process;
(F) No fees or costs are imposed on the claimant as part of any voluntary appeals process; and
(G) Any voluntary level of appeal requested by a claimant under this subparagraph shall be completed within 30 days from the date of the request for the voluntary appeal.
(f) Annual reports shall be made to the insurance commissioner regarding plan complaints, adverse determinations, claim denials, and prior authorization statistics in such form and containing such information as the commissioner may prescribe by rule or otherwise.
(g) If the claimant has filed an appeal and the carrier or other licensed entity has not issued a decision within the required time frames, the carrier or other licensed entity shall promptly provide the claimant with a statement of the claimant's right to file an external appeal as provided in RSA 420-J:5-a-RSA 420-J:5-e. The statement of appeal rights shall include a description of the process for obtaining external review of a determination, a copy of the written procedures governing external review, including the required time frames for requesting external review, and notice of the conditions under which expedited external review is available.
VI. In an appeal of a claim denial or other matter, the claimant may authorize a representative to pursue a claim or an appeal by submitting a written statement to the carrier or other licensed entity that acknowledges the representation.
VII. No fees or costs shall be assessed against a claimant related to a request for a grievance or appeal.
Source. 1997, 345:1. 2000, 18:6-10, 17. 2001, 207:12. 2003, 175:9, 10. 2005, 248:9, 10, 20. 2007, 289:27, 28, eff. Jan. 1, 2008. 2023, 154:4, eff. Sept. 26, 2023. 2024, 172:6, 7, eff. Jan. 1, 2025.
Section 420-J:5-a
420-J:5-a Right to External Review. –
I. A covered person shall have the right to independent external review of a determination by a health carrier or its designee utilization review entity when all of the following conditions apply:
(a) The subject of the request for external review is an adverse determination;
(b) The covered person has completed the internal review procedures provided by the carrier or other licensed entity pursuant to RSA 420-J:5, or the carrier or other entity has agreed to submit the determination to independent external review prior to completion of internal review, or the covered person has requested first or second level, standard or expedited review and has not received a decision from the carrier or other licensed entity within the required time frames;
(c)(1) The covered person or the covered person's authorized representative has submitted the request for external review in writing to the commissioner within 180 days of the date of the carrier or other licensed entity's denial decision provided pursuant to RSA 420-J:5, or if the carrier or other licensed entity has failed to make a first or second level, standard or expedited review decision that is past due, within 180 days of the date the decision was due;
(2) The covered person's or covered person's authorized representative's participation in any voluntary level of appeal offered by a carrier or other licensed entity pursuant to RSA 420-J:5, V(e)(2) shall not affect a covered person's ability to submit a request for external review. In the event that a covered person or covered person's authorized representative elects to proceed with a voluntary appeal, that person shall have 180 days from the date the decision is rendered on the voluntary appeal to submit a request for external review.
(d) The health carrier determination does not relate to any category of health care services that is excluded from the external review provisions of this chapter pursuant to paragraph II; and
(e) The request for external review is not based on a claim or allegation of provider malpractice, professional negligence, or other professional fault excluded from the external review provisions of this chapter pursuant to paragraph III.
II. Determinations relating to the following health care services shall not be reviewed under this chapter, but shall be reviewed pursuant to the review processes provided by applicable federal or state law:
(a) Health care services provided through Medicaid, the state Children's Health Insurance Program (Title XXI of the Social Security Act ), Medicare or services provided under these programs but through a contracted health carrier, except where those services are provided through private insurance coverage pursuant to the New Hampshire granite advantage health care program under RSA 126-AA in which case all provisions of this chapter shall apply.
(b) Health care services provided to inmates by the department of corrections.
(c) Health care services provided pursuant to a health plan not regulated by the state, such as self-funded plans administered by an administrative services organization or third-party administrator or federal employee benefit programs.
III. The external review procedures set forth in this chapter shall not be utilized to adjudicate claims or allegations of health care provider malpractice, professional negligence, or other professional fault against participating providers or medical directors.
Source. 2000, 18:13. 2001, 207:15. 2005, 248:21. 2012, 98:1. 2015, 64:1, eff. Aug. 1, 2015. 2018, 342:17, eff. Dec. 31, 2018.
Section 420-J:5-b
420-J:5-b Standard External Review. –
Standard external review shall be conducted as follows:
I. Within 7 business days after the date of receipt of a request for external review, the commissioner shall complete a preliminary review of the request to determine whether:
(a) The individual is or was a covered person under the health benefit plan;
(b) The determination that is the subject of the request for external review meets the conditions of eligibility for external review stated in RSA 420-J:5-a, I; and
(c) The covered person has provided all the information and forms required by the commissioner that are necessary to process a request for an external review.
II. Upon completion of the preliminary review pursuant to paragraph I, the commissioner shall immediately notify the covered person or the covered person's authorized representative in writing:
(a) Whether the request is complete; and
(b) Whether the request has been accepted for external review.
III. If the request is not complete, the commissioner shall inform the covered person or the covered person's authorized representative what information or documents are needed to make the request complete and to process the request. The covered person or the covered person's authorized representative shall submit such information or documentation within 10 days of being notified that the request was incomplete.
IV. If the request for external review is accepted, the commissioner shall:
(a) Include in the notice provided to the covered person pursuant to paragraph II a statement that if the covered person wishes to submit new or additional information or to present oral testimony via teleconference, such information shall be submitted, and the oral testimony shall be scheduled and presented, within 20 days of the date of issuance of the notice. However, the notice shall also explain that oral testimony shall be permitted only in cases when the commissioner determines, based on evidence provided by the covered person, that it would not be feasible or appropriate to present only written testimony.
(b) Immediately notify the health carrier in writing of the request for external review and its acceptance.
V. If the request for external review is not accepted, the commissioner shall inform the covered person or the covered person's authorized representative and the health carrier in writing of the reason for its non-acceptance.
VI. At the time a request for external review is accepted, the commissioner shall select and retain an independent review organization that is certified pursuant to RSA 420-J:5-d, I to conduct the external review. The commissioner shall not select the same independent review organization for each external review, but shall rotate among the certified independent review organizations, using all organizations equally. The commissioner may select and retain an independent review organization regardless of the rotation if the commissioner determines that the use of such independent review organization is necessary for the fair adjudication of the case in question.
VII. Within 10 days after the date of issuance of the notice provided pursuant to subparagraph IV(b), the health carrier or its designated utilization review organization shall provide to the selected independent review organization and to the covered person all information in its possession that is relevant to the adjudication of the matter in dispute, including but not limited to:
(a) The terms of agreement of the health benefit plan, including the evidence of coverage, benefit summary, or other similar document;
(b) All relevant medical records, including records submitted to the carrier by the covered person, the covered person's authorized representative, or the covered person's treating provider;
(c) A summary description of the applicable issues, including a statement of the health carrier's final determination;
(d) The clinical review criteria used and the clinical reasons for the determination;
(e) The relevant portions of the carrier's utilization management plan;
(f) Any communications between the covered person and the health carrier regarding the internal or external review; and
(g) All other documents, information, or criteria relied upon by the carrier in making its determination.
VIII. Failure by the health carrier or the covered person to provide the documents and information required in paragraph IV(a) or VII within the specified time frame shall not delay the conduct of the external review.
IX. The selected independent review organization shall review all of the information and documents received from the carrier pursuant to paragraph VII and any other information submitted by the covered person or the covered person's authorized representative or treating provider with the request for external review or pursuant to subparagraph IV(a) and any testimony provided . In addition to the information provided by the health carrier and the covered person or the covered person's authorized representative or treating provider, the independent review organization may consider any applicable, generally accepted clinical practice guidelines, studies or research, including those developed or conducted by the federal government, national or professional medical societies, boards, and associations. The independent review organization shall consider anew all previously determined facts, allow the introduction of new information, and make a decision that is not bound by decisions or conclusions made by the health carrier during internal review.
X. The selected independent review organization shall render a decision upholding or reversing the determination of the health carrier and notify the covered person or the covered person's authorized representative and the health carrier in writing within 20 days of the date that any new or additional information from the covered person is due pursuant to subparagraph IV(a). This notice shall include a written review decision that contains a statement of the nature of the grievance, references to evidence or documentation considered in making the decision, findings of fact, and the clinical and legal rationale for the decision, including, as applicable, clinical review criteria and rulings of law.
Source. 2000, 18:13, eff. Sept. 3, 2000.
Section 420-J:5-c
420-J:5-c Expedited External Review. –
Expedited external review shall be conducted as follows:
I. Expedited external review shall be available when the covered person's treating health care provider certifies to the commissioner that adherence to the time frames specified in RSA 420-J:5-b would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function.
II. Except to the extent that it is inconsistent with the provisions of this paragraph, all requirements for the conduct of standard external review specified in RSA 420-J:5-b shall apply to expedited external review. However, a person who meets the standard set forth in paragraph I for expedited external review, as well as the reviewability requirements set forth in RSA 420-J:5-b, I, may pursue expedited external review simultaneous with the internal review process in RSA 420-J:5.
III. At the time the commissioner receives a request for an expedited external review, the commissioner shall immediately make a determination whether the request meets the standard set forth in paragraph I for expedited external review, as well as the reviewability requirements set forth in RSA 420-J:5-b, I. If these conditions are met, the commissioner shall immediately notify the health carrier. If the request is not complete, the commissioner shall immediately contact the covered person or the covered person's authorized representative and attempt to obtain the information or documents that are needed to make the request complete.
IV. The commissioner shall select and retain an independent review organization that is certified pursuant to RSA 420-J:5-d, I to conduct the expedited external review.
V. The health carrier or its designated utilization review organization shall provide or transmit the documents and information specified in RSA 420-J:5-b, VII to the selected independent review organization by telephone, facsimile, or any other available expeditious method within one business day of receiving the commissioner's notice of the request for expedited external review pursuant to paragraph III.
VI. When handling a review on an expedited basis, the selected independent review organization shall make a decision and notify the carrier and the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the expedited external review is requested.
VII. If the notice provided pursuant to paragraph VI was not in writing, within 2 business days after the date of providing that notice, the selected independent review organization shall:
(a) Provide written confirmation of the decision to the covered person or the covered person's authorized representative and the health carrier; and
(b) Include the information set forth in RSA 420-J:5-b, X.
VIII. An expedited external review shall not be provided for determinations made by the health carrier on a retrospective basis.
IX. A covered person shall not be held liable to either the health plan, the hospital, the physician, or the services provider for the cost of services in excess of the applicable copayment, coinsurance, or deductible incurred, pending the independent review organization's determination of an expedited external review.
Source. 2000, 18:13. 2012, 98:2, eff. July 28, 2012.
Section 420-J:5-d
420-J:5-d Certification of Independent Review Organizations. –
I. The certification of independent review organizations shall be conducted as follows:
(a) The commissioner shall certify independent review organizations eligible to be selected to conduct external reviews under this section to ensure that an independent review organization satisfies the minimum qualifications established under paragraph II.
(b) The commissioner shall develop an application form for initially certifying and recertifying independent review organizations to conduct external reviews.
(c) Independent review organizations wishing to be certified shall submit the application form and include all documentation and information necessary for the commissioner to determine whether the independent review organization satisfies the minimum qualifications established under paragraph II.
(d) The commissioner may determine that accreditation by a nationally recognized private accrediting entity with established and maintained standards for independent review organizations that meet or exceed the minimum qualifications established under paragraph II is sufficient for certification under this paragraph.
(e) The commissioner shall maintain and periodically update a list of certified independent review organizations.
(f) Whenever the commissioner determines that an independent review organization no longer satisfies the minimum qualifications established under paragraph II, the commissioner shall terminate the certification of the independent review organization and remove it from the list of certified independent review organizations that is maintained by the commissioner pursuant to subparagraph I(e).
II. To be certified under paragraph I to conduct external reviews, an independent review organization shall meet the following minimum qualifications:
(a) It shall develop and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process.
(b) It shall establish and maintain a quality assurance program that:
(1) Ensures that external reviews are conducted within the specified time frames and required notices are provided in a timely manner;
(2) Ensures the selection of qualified and impartial clinical peer reviewers to conduct external reviews on behalf of the independent review organization with suitable matching of reviewers to specific cases;
(3) Ensures the confidentiality of medical and treatment records; and
(4) Ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this section.
(c) It shall agree to maintain and provide to the commissioner such information as may be required to fulfill the provisions and purposes of this section.
(d) It shall assign clinical peer reviewers to conduct external reviews who are physicians or other appropriate health care providers and who:
(1) Are experts in the treatment of the covered person's medical condition that is the subject of the external review;
(2) Are knowledgeable about the recommended health care service or treatment through actual clinical experience;
(3) Hold a non-restricted license in a state of the United States and, for physicians, a current certification by a specialty board recognized by the American Board of Medical Specialties in the area or areas appropriate to the subject of the external review;
(4) Have no history of disciplinary actions or sanctions that have been taken or are pending by any hospital, governmental agency, or regulatory body; and
(5) Have agreed to disclose any potential conflict of interest.
(e) It shall be free of any conflict of interest. To meet this qualification, an independent review organization may not own or control or in any way be owned or controlled by a health carrier, a national, state, or local trade association of health carriers, or a national, state, or local trade association of health care providers. In addition, in order to qualify to conduct an external review of a specific case, neither the independent review organization selected to conduct the external review nor any clinical peer reviewer assigned by the independent organization to conduct the external review may have a material professional, familial or financial interest in any of the following:
(1) The health carrier that is the subject of the external review;
(2) Any officer, director, or management employee of the health carrier that is the subject of the external review;
(3) The health care provider or the health care provider's medical group or independent practice association recommending the health care service or treatment that is the subject of the external review;
(4) The facility or institution at which the recommended health care service or treatment would be provided;
(5) The developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended for the covered person whose treatment is the subject of the external review; or
(6) The covered person or the covered person's authorized representative.
(f) Its charges for services provided shall be competitive and reasonable.
(g) It shall be accredited by a nationally recognized accreditation organization to perform external reviews.
(h) For the purpose of allowing in-state health care providers to act as clinical peer reviewers in the conduct of external reviews, the commissioner may determine, in specific cases, that an affiliation with a hospital, an institution, an academic medical center, or a health carrier provider network does not in and of itself constitute a conflict of interest which is sufficient to preclude that provider from acting as a clinical peer reviewer, so long as the affiliation is disclosed to the covered person or the covered person's authorized representative.
(i) The following organizations shall not be eligible for certification to conduct external reviews:
(1) Professional or trade associations of health care providers;
(2) Subsidiaries or affiliates of such provider associations;
(3) Health carrier or health plan associations; and
(4) Subsidiaries or affiliates of health plan or health carrier associations.
Source. 2000, 18:13. 2012, 98:3, eff. July 28, 2012.
Section 420-J:5-e
420-J:5-e General Provisions Regarding External Review. –
I. The health carrier against which a request for external review is filed shall pay the cost of the external review. Except under the circumstances described below in this paragraph, such costs shall not exceed $1,500. The commissioner shall notify the independent review organizations of the cost limitation for conducting an external review. The cost for an external review may exceed $1,500 if the commissioner determines an additional cost is necessary to ensure the fair adjudication of the case in question.
II. The external review decision of the independent review organization shall be binding on the health carrier and shall be enforceable by the commissioner pursuant to the penalty provisions of RSA 420-J:14. The external review decision of the independent review organization shall be binding on the covered person except to the extent the covered person has other remedies available under federal or state law. The external review process shall not be considered an adjudicative proceeding within the meaning of RSA 541-A, and the external review decision of the independent review organization shall not be subject to rehearing and appeal pursuant to RSA 541.
III. An independent review organization shall maintain all standards of confidentiality. The records and internal materials prepared for specific reviews by an independent review organization under this section shall be exempt from public disclosure under RSA 91-A.
IV. An external review organization acting in good faith shall have immunity from any civil or criminal liability or professional discipline as a result of acts or omissions with respect to any external review, unless the acts or omissions constitute willful and wanton misconduct.
V. The right to external review under this chapter shall not be construed to change the terms of coverage under a health benefit plan nor shall the health carrier retaliate against the covered person for exercising his or her right to an independent external review.
VI. When requested by the covered person, the commissioner shall provide consumer assistance in pursuing the internal grievance procedures under RSA 420-J:5 and the external review process under RSA 420-J:5-a-420-J:5-e.
VII. The commissioner shall report annually to the governor and the legislature on the number of grievances subjected to external review, the number of decisions resolved wholly or partially in favor of the covered person, and the number of decisions resolved wholly or partially in favor of the health carrier. Such reports shall also include a separate statement of the number of cases in which the external review was terminated as a result of a reversal by the health carrier of its adverse determination after the receipt of new or additional information from the covered person or the covered person's authorized representative and the number of cases in which the covered person and the health carrier agreed to resolve the dispute prior to a final determination by the independent review organization.
VIII. If, based on the evidence presented during the external review process, the commissioner determines that the health carrier's medical director, in the conduct of his or her duties, may have committed misconduct as set forth in RSA 329:17, VI, the commissioner shall document such findings and transmit them in a separate report to the board of medicine.
Source. 2000, 18:13, eff. Sept. 3, 2000.
Section 420-J:6
420-J:6 Utilization Review. –
I. Written standards and procedures.
(a) Each health carrier conducting utilization review directly or indirectly through a contracted utilization review entity shall have written procedures for carrying out its utilization review processes and shall file such procedures with the commissioner on or before April 1 of each year. Health carriers shall conform to the standards of either the Utilization Review Accreditation Commission or the National Committee for Quality Assurances and are subject to all applicable rules issued pursuant to RSA 420-E:7.
(b) The written procedures shall describe the categories of health care personnel that perform utilization review activities and whether or not such individuals are licensed in this state, and shall address at a minimum: prior authorization requirements; second opinion programs; pre-hospital admission certification; pre-inpatient service eligibility certification; and concurrent hospital review to determine appropriate length of stay; as well as the process used by the health carrier to preserve confidentiality of medical information.
(c) The clinical review criteria used by a health carrier or its contracted utilization review entity shall be in writing and:
(1) Developed with input from appropriate actively practicing practitioners in the health carrier's service area;
(2) Updated at least biennially and as new treatments, applications, and technologies emerge;
(3) Developed in accordance with the standards of national accreditation entities;
(4) Based on current, nationally accepted standards of medical practice; and
(5) If practicable, evidence-based.
(d) All contracts that health carriers make with a utilization review entity shall be available to the commissioner upon request.
II. Disclosure of prior authorization requirements and publication of prior authorization performance indicators.
(a) A health carrier conducting utilization review directly, or indirectly through a contracted utilization review entity, shall make any current prior authorization requirements and restrictions readily accessible on its website to enrollees, health care professionals, and the general public. This includes the written clinical criteria. Requirements shall be described in detail, but also in easily understandable language.
(b) If a health carrier or its contracted utilization review entity intends either to implement a new prior authorization requirement or restriction, or amend an existing requirement or restriction, the health carrier shall:
(1) Ensure that the new or amended requirement is not implemented unless the health carrier's website has been updated to reflect the new or amended requirement or restriction.
(2) Provide contracted health care providers of enrollees written notice of the new or amended requirement or amendment no less than 60 days before the requirement or restriction is implemented.
(c) Effective March 31, 2026, health carriers conducting utilization review directly, or indirectly through a contracted utilization review entity, shall make prior authorization metrics as specified in 45 C.F.R section 156.223 available to the commissioner, and the commissioner shall display relevant corresponding data, in a carrier specific format, on a website maintained by the insurance department in a readily accessible format.
III. Qualifications of reviewers making medical necessity determinations. A health carrier conducting utilization review directly, or indirectly through a contracted utilization review entity, shall ensure that all medical necessity determinations are made by a qualified health care provider. A reviewing provider shall:
(a) Have appropriate medical and professional expertise and credentials to competently apply the health carrier's clinical review criteria.
(b) Make the medical necessity determination under the clinical direction of one of the health carrier's own medical directors or one of the contracted utilization review entity's medical directors who is responsible for the review of health care services provided to covered persons who are residents of New Hampshire.
IV. Medical directors. Each health carrier that conducts utilization review shall employ one or more medical directors who shall have responsibility for all utilization review techniques and methods and their administration and implementation and who shall be licensed in New Hampshire under RSA 329. Nothing in this section shall be construed to preclude a medical director from consulting with or relying on the advice of a physician licensed in this state or any other state. Nothing in this section shall be construed as creating any civil liability to the medical director for the medical director's alleged negligent performance of the aforementioned responsibilities for utilization review.
V. Timeliness standards for processing prior authorization requests submitted electronically. Health carriers conducting utilization review directly, or indirectly through a contracted utilization review entity, shall meet the following time frames for prior authorization determinations requested by participating providers or facilities that submit the prior authorization request through an electronic prior authorization process as designated by the health carrier:
(a) In non-urgent circumstances, health carriers requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination within 7 calendar days of obtaining all information necessary to make the determination. Any request that the health carrier makes for additional information necessary to make the determination shall be made within 7 calendar days of the prior authorization request date.
(b) In urgent circumstances, health carriers requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination as expeditiously as the covered person's medical condition requires, and not later than 72 hours after obtaining all information necessary to make the determination. Any request that the health carrier makes for additional information necessary to make the determination shall be made as expeditiously as required to meet the 72-hour timeline, assuming a timely response from the treating provider.
VI. Timeliness standards for processing prior authorization requests submitted non-electronically. Health carriers conducting utilization review directly, or indirectly through a contracted utilization review entity, shall meet the following time frames for prior authorization determinations requested by participating providers or facilities that submit the prior authorization request through a non-electronic prior authorization process:
(a) In non-urgent circumstances, health carriers requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination within 14 calendar days of obtaining all information necessary to make the determination. Any request that the health carrier makes for additional information necessary to make the determination shall be made within 7 calendar days of the prior authorization request date.
(b) In urgent circumstances, health carriers requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination as expeditiously as the covered person's medical condition requires, and not later than 72 hours after obtaining all information necessary to make the determination. Any request that the health carrier makes for additional information necessary to make the determination shall be made as expeditiously as required to meet the 72-hour timeline, assuming a timely response from the treating provider.
VII. In paragraphs V and VI, "all information necessary to make the determination" shall include any information that may have been provided through a peer-to-peer review.
VIII. A prior authorization request shall be considered approved if the health carrier fails to notify the covered person and the covered person's health care provider of the prior authorization determination within the timeliness standards for making a determination after obtaining all necessary information.
IX. Duration of an approval of a prior authorization request.
(a) Health carriers conducting utilization review directly, or indirectly through a contracted utilization review entity, shall not revoke, limit, condition, or restrict a prior authorization if care is provided within 60 business days from the date the health care provider received approval of the prior authorization request.
(b) A health carrier conducting utilization review directly, or indirectly through a contracted utilization review entity, shall pay a participating health care provider at the contracted payment rate for a health care service provided by the health care provider pursuant to a prior authorization determination that coverage is available unless:
(1) The health care provider materially misrepresented the health care service in the prior authorization request;
(2) The health care service was no longer a covered benefit on the day it was provided;
(3) The health care provider was no longer contracted with the covered person's health carrier on the date the care was provided;
(4) The health care provider failed to meet the health carrier's timely filing requirements;
(5) The patient was no longer eligible for health care coverage on the day the care was provided; or
(6) The health carrier does not have liability for the claim or for a part of the claim for any reason under the covered person's coverage policy, the provider contract between the health carrier and the participating provider, or any other reason applicable at law or in equity.
X. Option to request a peer-to-peer review. When a health carrier requires prior authorization for an item or service, the carrier shall offer the provider the opportunity to request a peer-to-peer review of a prior authorization request in which the provider is able to have a direct conversational exchange with a medical director or a designated provider who is a clinical peer about the basis for the prior authorization request. A "clinical peer" in this context shall be a health care professional who has demonstrable expertise to review a case, whether or not the reviewing professional is in the same or a similar specialty as the provider. The peer-to-peer review may be requested before the carrier's prior authorization determination or after a prior authorization denial and before a formal grievance request has been made. The peer-to-peer review shall be made available by the health carrier within 2 business days of the request. If the peer-to-peer review is requested after a prior authorization denial, the heath carrier shall treat the review request as a request for reconsideration that is external to the grievance process and shall provide the provider and the covered person a written determination containing a statement of the specific reasons for the reconsideration determination with reference to the information provided in the peer-to-peer review. The written reconsideration determination shall be provided within 7 business days of the peer-to-peer review.
XI. Nothing in this section shall be construed to contravene a covered person's right to external review under RSA 420-J:5-a. Unless otherwise required by law, the prior authorization requirements set out in this chapter shall apply to all medical services and items.
Source. 1997, 345:1. 2000, 18:5, 15. 2001, 207:13. 2003, 276:11, eff. July 1, 2003. 2024, 172:5, eff. Jan. 1, 2025.
Section 420-J:6-a
420-J:6-a Obstetrical-Gynecological Coverage. –
I. Health plans shall not require prior authorization by a covered person's primary care provider for coverage of the following services provided by participating providers who specialize in obstetrics and gynecology:
(a) Maternity care;
(b) An annual gynecological visit; and
(c) Follow-up care for obstetrical or gynecological conditions identified during such maternity care or annual gynecological visit.
II. Health plans may establish reasonable requirements for participating obstetricians and gynecologists to communicate with the covered person's primary care provider regarding the covered person's condition, treatment, and any need for follow-up care.
Source. 1998, 319:1, eff. Jan. 1, 1999.
Section 420-J:6-b
420-J:6-b Self-Referrals for Chiropractic Care. –
A health benefit plan under this chapter offering chiropractic benefits shall provide benefits to a covered person who utilizes services of a chiropractic provider (doctor of chiropractic) by self-referral for 12 visits under the following conditions:
I. Unless otherwise provided for by the health benefits plan, self-referral visits shall not apply to wellness care visits.
II. A covered person may utilize the services of a doctor of chiropractic as defined in RSA 316-A, without discrimination relative to access and fees, subject to the terms and conditions of the policy.
III. The health benefit plan shall fully disclose to the certificate holder in clear and understandable language the exact terms and conditions of each option that the certificate holder has purchased along with the co-payments or other cost-sharing features of each option.
IV. Within 10 working days of the first visit or consultation, the doctor of chiropractic shall send to the health benefit plan, or its designee, the chiropractic case findings. This shall be sufficient documentation for the initial 12 visits.
V. After 12 self-referral visits, a covered person who is continuing chiropractic care may be subject to utilization review from the health plan, or its designee, for the purpose of continued care. A provider of the same specialty shall be consulted when making any utilization review determination under this section.
VI. If the chiropractic provider recommends care beyond 12 visits, the participating doctor of chiropractic shall send to the insurer, or its designee, documentation containing information on the covered person's progress and necessity of care as well as a care plan for extended chiropractic care. The care recommendation shall be deemed authorized if the health benefit plan does not respond to the care recommendation within 7 business days. If the doctor of chiropractic fails to provide the required documentation, the insured or its covered person shall not be liable to the chiropractic provider for any unpaid fees.
VII. The covered person shall retain the right to choose chiropractic care on an elective, self-pay, fee-for-service basis; no entity regulated under this chapter shall prohibit a doctor of chiropractic from continuing care on an elective, self-pay, fee-for-service basis.
VIII. Nothing in this section is intended to limit the health plan's ability to credential providers or structuring with network providers.
Source. 2000, 14:1, eff. April 18, 2000.
Section 420-J:6-c
420-J:6-c Third-Party Payment of Covered, Court-Ordered Services. –
The existence of a court order under RSA 169-B, RSA 169-C, or RSA 169-D for a service, program, or placement that is covered under any insurance for the minor shall not be considered in determining qualification for third-party payment under such insurance. Benefits for such services shall be subject to the same dollar limits, deductibles, co-payments and co-insurance factors and to the terms and conditions of the policy or certificate, including any managed care provisions. However, the claimant or claimant's representative shall have 48 hours from the commencement of a court-ordered service, placement, or program to seek any pre-authorization, pre-certification, or referral required under the terms of the policy. The determination of these preservice claims for court-ordered services for a minor shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 48 hours after receipt of the request and sufficient information, unless the claimant or claimant's representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable. In the case of such failure, the insurer shall notify the claimant or claimant's representative within 24 hours of receipt of the request and shall advise the claimant or claimant's representative of the specific information necessary to determine to what extent benefits are covered or payable. The claimant or claimant's representative shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. Thereafter, notification of the claim determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of:
I. The insurer's receipt of the specified additional information; or
II. The end of the period afforded the claimant or claimant's representative to provide the specified additional information.
Source. 2004, 117:4, eff. Aug. 15, 2004.
Section 420-J:6-d
420-J:6-d Coverage for Dependents. –
If the coverage for dependent children includes coverage for dependent children who are full-time students, as defined by the appropriate educational institution, beyond the age of 18, such dependent coverage shall include coverage for a dependent's medically necessary leave of absence from school for a period not to exceed 12 months or the date on which coverage would otherwise end pursuant to the terms and conditions of the policy, whichever comes first. Any breaks in the school semester shall not disqualify the dependent child from coverage under this section. Documentation and certification of the medical necessity of a leave of absence shall be submitted to the insurer by the student's attending physician and shall be considered prima facie evidence of entitlement to coverage under this section. The date of the documentation and certification of the medical necessity of a leave of absence shall be the date the insurance coverage under this section commences.
Source. 2007, 289:29, eff. Jan. 1, 2008.
Section 420-J:6-e
420-J:6-e Coverage for Medically Necessary Dental Services. –
Health carriers shall provide coverage for medically necessary dental services resulting from an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received or authorized within 3 months of the date of the injury. Treatment made necessary due to injury to the jaw and oral structures other than teeth shall be covered without time limit. Coverage under this section shall be subject to such other terms and conditions of the policy that may apply.
Source. 2019, 113:3, eff. Aug. 20, 2019.
Section 420-J:7
420-J:7 Network Adequacy. –
I. A health carrier shall maintain a network that is sufficient in numbers, types, and geographic location of providers to ensure that all services to covered persons will be accessible without unreasonable delay.
II. The commissioner shall adopt rules under RSA 541-A for a health carrier's network adequacy. Such rules shall establish, but not be limited to:
(a) Waiting times for appointments for non-emergency care.
(b) Choice of and access to providers for specialty care, specifically addressing the needs of the chronically ill, mentally ill, persons with substance use disorder, developmentally disabled or those with a life threatening illness.
(c) Standards for geographic accessibility, which shall include standards for access to the provision of durable medical equipment requiring a prescription. However, such standards shall not restrict an insurer's ability to provide prescriptions for durable medical equipment that are shipped to the patient by postal service or other common or private carrier, and shall not apply to durable medical equipment devices used exclusively for the administration of medication.
(d) Hours of operation for the carrier, including any entities performing prior approval or pre-authorization functions.
(e) Standards for addressing in-network access to hospital based providers, such as anesthesiologists, radiologists, pathologists, and emergency medicine physicians.
III. The health carrier shall keep, at its place of business, a detailed description of the health carrier's compliance with rules adopted pursuant to RSA 420-J:7, II as well as its procedures for monitoring network adequacy.
IV. Annually, the health carrier shall submit a report to the commissioner demonstrating compliance with the rules for network adequacy.
V. The commissioner shall make available to the public information regarding each health carrier's managed care network.
Source. 1997, 345:1. 2008, 311:1, eff. Aug. 31, 2008. 2017, 214:1, eff. Jan. 1, 2018. 2018, 356:3, 4, eff. July 1, 2018. 2025, 191:21, eff. Sept. 13, 2025.
Section 420-J:7-a
420-J:7-a Repealed by 2007, 33:2, eff. July 13, 2007. –
Section 420-J:7-b
420-J:7-b Prescription Drugs. –
I. (a) Every health benefit plan that provides prescription drug benefits is required to provide prospective enrollees, and covered persons, a description of the prescription drug benefit plan. Among the specific items that shall be included in the description are:
(1) The procedure a covered person must follow to obtain drugs and medications that are subject to a plan list or plan formulary.
(2) A description of the drug formulary and the plan's exception process.
(3) A description of the extent to which a covered person will be reimbursed for the cost of a drug that is not on a plan list or formulary.
(b) Health carriers shall provide upon request additional information to covered persons related to specific drugs that are not on the formulary.
II. Every health benefit plan that provides prescription drug benefits shall maintain an expeditious exception process, not to exceed 48 hours, by which covered persons may obtain coverage for a medically necessary nonformulary prescription drug or for a nonformulary prescription drug that was available during the previous 12 months. The exception process shall begin when the prescribing provider has submitted a request with a clinical rationale for the exception to the health benefit plan. The exception process shall also begin when a covered person has submitted a non-clinical request for access to a drug approved by the federal Food and Drug Administration for treating a specific condition when such drug was available on the formulary during the previous 12 months. A prescription that requires an exception for coverage shall be considered approved if the exception process exceeds 48 hours.
II-a. No health benefit plan that provides prescription drug benefits and establishes the specific sequence in which prescription drugs for a medical condition are to be prescribed shall require failure on the same medication on more than one occasion for patients continuously enrolled in the plan. Nothing in this section shall be construed to prevent a health care provider from prescribing a medication to the same patient on more than one occasion, when he or she determines it is medically appropriate.
II-b. Every health benefit plan that provides prescription drug benefits and requires prior authorization for covered drugs in the formulary shall respond to a prior authorization request within 2 business days. The prior authorization process shall begin when the prescribing provider has submitted a request with a complete clinical rationale to the health carrier or pharmacy benefits manager. A prescription that requires a prior authorization for coverage shall be considered approved if the prior authorization process exceeds 2 business days.
III. Every health plan that provides prescription drug benefits shall provide written notice in a conspicuous font and size to covered persons affected by deletions to the plan list or plan formulary, provide an explanation of the exception process by which a covered person can access nonformulary medically necessary prescription drugs, and provide a toll-free telephone number through which a covered person can request additional information. For purposes of this paragraph, covered persons affected by deletions to the plan list or plan formulary shall include those covered persons for whom the health plan has provided coverage for the deleted prescription drugs during the 12-month period immediately prior to the deletion. Upon notification to covered persons, the health benefit plan shall allow at least 45 days before implementation of any formulary deletions; provided, however, that advance notice shall not be required if the federal Food and Drug Administration has determined that a prescription drug on the health benefit plan's formulary is unsafe. For purposes of this section, "conspicuous font and size" shall mean a font that is at least 12 point in size and in an easily legible font. If a covered person avails himself or herself of the exception process as outlined in 420-J:7-b, II, the medication shall be covered by the health plan until there is a resolution of the exception process.
IV. Every health benefit plan that provides prescription drug benefits shall maintain, as part of its records, all of the following information, which shall be made available to the commissioner upon request: the complete drug formulary or formularies of the plan, if the plan maintains a formulary, including a list of the prescription drugs on the formulary of the plan by major therapeutic category with an indication of whether any drugs are preferred over the other drugs.
IV-a. Every health benefit plan that provides prescription drug benefits shall provide notice of deletions to the plan list or plan formulary to all covered persons at least annually.
IV-b. Every health benefit plan that provides prescription drug coverage shall also provide notice of additions to the plan list or formulary to all covered persons at least annually. However, the requirements of this paragraph shall not apply to any health benefit plan that adds prescription drugs to its plan list or formulary upon approval by the federal Food and Drug Association.
IV-c. (a) Beginning July 1, 2017, all health insurers, health maintenance organizations, health services corporations, medical services corporations, and preferred provider programs may, when requiring prior authorization for a prescription drug, use and accept the prior authorization paper forms or electronic standard described in this paragraph.
(b) Beginning December 31, 2017, all health insurers, health maintenance organizations, health services corporations, medical services corporations, and preferred provider programs shall, when requiring prior authorization for a prescription drug, use and accept only the prior authorization paper forms or electronic standard described in this paragraph.
(c) On or before March 1, 2017, the commissioner shall adopt rules, pursuant to RSA 541-A, specifying the contents and format of the uniform prior authorization paper forms and the electronic prior authorization standard, consistent with the requirements of this paragraph. In developing the paper forms and the electronic standard, the commissioner shall seek input from interested stakeholders, including, but not limited to, prescribers, pharmacists, carriers, and prescription benefits managers, and shall support adoption of nationally recognized standards for electronic prior authorization of prescription drugs, including those provided by the National Council for Prescription Drug Programs or an equivalent organization as available.
(d) The prior authorization paper forms adopted under this paragraph shall not exceed 2 pages in length.
(e) Nothing in this paragraph shall require a carrier or pharmacy benefits manager to use electronic prior authorization. A carrier or pharmacy benefits manager shall not require use of electronic prior authorization when:
(1) A pharmacist or prescriber lacks broadband Internet access;
(2) A pharmacist or prescriber has low patient volume;
(3) A pharmacist or prescriber has opted-out for a certain medical condition or for a patient request;
(4) A pharmacist or prescriber lacks an electronic medical record system;
(5) The electronic prior authorization interface does not provide for the pre-population of prescriber and patient information; or
(6) The electronic prior authorization interface requires an additional cost to the prescriber.
(f) Nothing in this section shall prohibit the use of prior authorization for prescription drug benefits.
(g) This section shall apply to RSA 420-J and shall not apply to the Medicaid managed care program under RSA 126-A:5, XIX.
V. Every health benefit plan that provides coverage for prescription drugs or devices, or administers such a plan, or which contracts with an entity providing such prescription drug coverage, including but not limited to pharmacy benefit manager companies, shall issue to covered persons a card or other technology containing uniform prescription drug information. The uniform prescription drug information card or technology shall include all of the fields required by the health insurance provider for claims processing in a clear, readable, and understandable manner on the card or other technology issued and shall include, at a minimum, the following information:
(a) The name or trademark logo of the insurer and, if another company administers the prescription benefit, the name or trademark logo of the benefit administrator.
(b) The covered person's name and identification number.
(c) All of the electronic transaction routing information required by the insurer or its benefit administrator in order for the pharmacy to electronically process a prescription claim, including but not limited to the BIN number labeled as such or the Processor Control Number labeled as such, or both.
VI. All subscriber health insurance cards issued after January 1, 2004 shall contain the information required under paragraph V.
VII. A new uniform prescription drug information card, as required under paragraph V, shall be issued by health benefit plan upon enrollment of new members and when reissuing a new card to current members when there is a change in the covered person's pharmacy coverage that affects data contained on the card.
VIII. Every health benefit plan that provides prescription drug benefits shall allow its covered persons to purchase an up-to-90-day supply of covered prescription drugs on the covered person's health benefit plan formulary at one time at a pharmacy of the insured's choice within the insurer's network, provided that the insured can demonstrate that such drug has been taken by the insured for a continuous period of one year and provided that such drug is not subject to the health benefit plan's utilization management, prior authorization, or pre-certification requirements. Controlled substances as identified by the United States Drug Enforcement Administration are exempt from this paragraph. Nothing in this paragraph shall be construed to limit the health benefit plan's ability to establish co-payments, coinsurance deductibles, or other member cost shares. A retail pharmacy dispensing a 90-day supply of covered prescription drugs under this paragraph shall comply with any specified terms, conditions, and reimbursement rate which the health benefit plan may require for mail order pharmacies that fill 90-day prescriptions.
IX. (a) Every health benefit plan that provides prescription drug benefits shall allow its covered persons to obtain an emergency prescription for up to a 72-hour supply of covered prescription drugs on the covered person's health benefit plan formulary or a prescription drug that was deleted from the formulary within the last 90 days in the event a prescription requires prior authorization or an exception by an insurance carrier and the prior authorization or exception has neither been approved nor denied and a pharmacist has determined the medication is essential as provided in RSA 318:47-i. Such reimbursement shall be according to the payment rates of the provider contract. If authorization or exception is subsequently denied, the carrier shall reimburse the pharmacist for the prescription as given based on the pro-rated amount they would have otherwise received under the terms of the provider contract.
(b) The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted:
(1) Agents when used for anorexia, weight loss, or weight gain.
(2) Agents when used to promote fertility.
(3) Agents when used for cosmetic purposes or hair growth.
(4) Agents when used for the symptomatic relief of cough and colds.
(5) Agents when used to promote smoking cessation.
(6) Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
(7) Nonprescription drugs, except, in the case of pregnant women when recommended by or under the supervision of a physician, agents approved by the Food and Drug Administration under the over-the-counter monograph process for purposes of promoting, and when used to promote, tobacco cessation.
(8) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.
(9) Barbiturates.
(10) Benzodiazepines.
(11) Agents when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration.
X. (a) A pharmacy benefits manager or insurer shall require a contracted pharmacy to charge an enrollee or insured person the pharmacy's usual and customary price of filling the prescription or the contracted copayment, whichever is less.
(b) Once it has settled a claim for filling a prescription for an enrollee or insured person and notified the pharmacy of the amount the pharmacy benefits manager or insurer shall pay to the pharmacy for that prescription, the pharmacy benefits manager or insurer shall not lower the amount to be paid to the pharmacy by the pharmacy benefits manager or the insurer for such settled claim; provided, however, that this paragraph shall not apply if the claim was submitted fraudulently or with inaccurate or misrepresented information.
(c) The commissioner shall adopt rules under RSA 541-A to implement this paragraph. Such rules shall include procedures for addressing complaints, provisions for enforcement, and for reporting to the office of professional licensure and certification on the status of complaints referred.
XI. Health carriers shall have access to or maintain within their data systems amounts paid to pharmacies and other health care providers for all prescription drugs on behalf of their covered members. Carriers shall have access to or maintain a record of any amounts due to the pharmacy from the covered member in the form of cost sharing, such as copayments, deductibles, or coinsurance. The health carrier shall be responsible for assuring timely access to this information even when the prescription drug benefit is administered by a pharmacy benefit manager or similar entity.
XII. A health carrier shall not, either directly or indirectly:
(a) Prohibit an in-network retail pharmacy from:
(1) Mailing or delivering a prescription drug to an enrollee as an ancillary service of the in-network retail pharmacy provided that confirmation of delivery is obtained.
(2) Charging a shipping or handling surcharge to an enrollee who requests that the in-network retail pharmacy mail or deliver a prescription drug to the enrollee as an ancillary service provided the enrollee receives a disclosure from the in-network retail pharmacy regarding any surcharge to be charged to the patient for the delivery of a prescription drug, including that the surcharge may not be reimbursable by the plan sponsor or health carrier.
(3) Offering the ancillary services described in subparagraph I(a) to an enrollee.
(b) Charge an enrollee who uses an in-network retail pharmacy that offers to mail or deliver a prescription drug to an enrollee as an ancillary service a surcharge for the delivery of a prescription drug or copayment that is higher than the surcharge or copayment the enrollee would pay if the enrollee used an in-network retail pharmacy that does not offer to mail or deliver a prescription drug to an enrollee as an ancillary service.
(c) For purposes of this section, a retail pharmacy shall not include a "mail-order pharmacy" as defined in RSA 318:1, VII-b.
Source. 1999, 286:1. 2003, 286:5. 2004, 187:15-17. 2007, 73:2. 2013, 257:30; 262:1. 2014, 2:1, eff. April 21, 2014; 120:2, eff. Aug. 15, 2014; 311:3, eff. Jan. 1, 2015. 2016, 221:6, eff. June 9, 2016; 228:2, eff. June 9, 2016. 2019, 137:1, eff. Aug. 24, 2019; 180:1, 2, eff. Sept. 8, 2019. 2020, 13:8, eff. Jan. 1, 2021. 2021, 149:2, eff. Sept. 21, 2021. 2024, 327:138, eff. July 1, 2024.
Section 420-J:7-c
420-J:7-c Disqualification of Certain Physicians Prohibited. –
A physician who is part of a health carrier's provider network on December 31, 2000, shall not be disqualified from participating in that network solely because such physician is not certified by a member board of the American Board of Medical Specialties.
Source. 2000, 248:1, eff. Aug. 8, 2000.
Section 420-J:7-d
420-J:7-d Continued Access to Care Subsequent to a Provider Contract Termination. –
The commissioner may extend the period of continued access to care subsequent to a provider contract termination provided for under RSA 420-J:8, XI for up to an additional 60-day period.
Source. 2003, 284:3, eff. July 1, 2003.
Section 420-J:7-e
420-J:7-e Notice of Consumer Rights. –
A health carrier shall, at least annually, in a conspicuous communication as approved by the commissioner which may be included as an insert in an annual mailing or by electronic communication, notify each covered person of his or her consumer rights under this chapter, including, but not limited to, appeal rights and the ability to access services out-of-network in the event covered services are not available in-network. A health carrier shall also notify covered persons of the right to access out-of-network services when the covered person contacts the health carrier directly requesting assistance finding clinically appropriate in-network care. A health carrier shall also provide notification to covered persons of their right to appeal whenever a covered person contacts the health carrier regarding a denial of coverage or when a health carrier verbally informs the covered person of the denial of coverage.
Source. 2017, 214:2, eff. Jan. 1, 2018.
Section 420-J:8
420-J:8 Provider Contract Standards. –
I. Every contract between a health carrier and a participating provider shall set forth a hold harmless provision specifying protection for covered persons. This provision shall include language substantially as follows:
(a) Provider agrees that in no event, including but not limited to nonpayment by the health carrier or intermediary, insolvency of the health carrier or intermediary, or breach of this agreement, shall the provider bill, charge, collect a deposit from, seek payment or reimbursement from, or have recourse against a covered person or a person acting on behalf of the covered person (other than the health carrier or intermediary) for services provided pursuant to this agreement. This agreement does not prohibit the provider from collecting coinsurance, deductibles, or copayments, as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to covered persons. Nor does this agreement prohibit a provider and a covered person from agreeing to continue services solely at the expense of the covered person, as long as the provider has clearly informed the covered person that the health carrier may not cover or continue to cover a specific service or services. Except as provided in this chapter, this agreement does not prohibit the provider from pursuing any available legal remedy.
(b) Provider further agrees that:
(1) This provision shall survive the termination of this agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the covered person; and that
(2) This provision supersedes any oral or written contrary agreement now existing or hereafter entered into between provider and covered person or persons acting on their behalf.
(c) Any modifications, additions or deletions to the provisions of this section shall become effective on a date no earlier than 15 business days after the commissioner has received written notice of such proposed changes.
II. The execution of a contract by a health carrier shall not relieve the health carrier of its liability to any person with whom it has contracted for the provision of services, nor of its responsibility for the compliance with any law or rule.
III. The health carrier shall maintain provider and intermediary contracts at its principal place of business in this state, or the health carrier shall have access to all contracts and provide copies to facilitate regulatory review upon 15 business days prior written notice from the commissioner.
IV. No contract between a health carrier and a physician, for the purpose of delineating the rights and obligations of the parties within the provider network, shall limit the liability of the health carrier for any actions of the physician for which the health carrier might otherwise be liable.
V. No contract between a health carrier and a health care provider shall limit what information such health care provider may disclose to patients or to prospective patients regarding the provisions, terms, or requirements of the health carrier's products as they relate to the needs of such provider's patients except for trade secrets of significant competitive value.
VI. No contract shall use the term physician for the purpose of allowing a health carrier to avoid contracting with other health care professionals for health care services. A physician shall mean a person licensed to practice medicine under RSA 329. Nothing in this section shall be construed to require a health carrier to contract with a health care provider.
VII. A health carrier shall allow a participating provider 60 days from the postmarked date to review any proposed contract and any modifications to an existing contract, excluding those modifications that are expressly permitted under the existing contract.
VIII. (a) No contract between a health carrier and a participating provider shall contain any payment or reimbursement provision the terms of which creates an inducement for the provider to not provide medically necessary care to covered persons. Nothing in this section shall be construed to prohibit the use of payment arrangements between a health carrier and a participating provider or provider group which involve capitation, withholds or other arrangements.
(b) Prior to the execution of a health care provider contract, a health carrier shall furnish to the contracting entity, in writing or in electronic format, a complete copy of the proposed contract including all attachments and exhibits. The health carrier shall also make available to the contracting entity, in writing or in electronic format, the most current provider manual.
(c) The contracting entity may request that a health carrier disclose the fees applicable to specified procedure codes that pertain to the entity's practice or specialty or a method or process that allows the contracting entity to determine the fees pursuant to the terms of the contract. Upon request by the contracting entity, the insurer shall furnish, in writing or in an electronic format, the requested procedure codes within 30 calendar days from receipt of the request.
(d) No provider contract shall allow for a material change in the applicable fee schedule unless notice of such change is given at least 60 days in advance of the effective date.
(e) Provider contracts that include payment for mammography shall include distinct recognition of and additional payment for industry standard coding relating to mammography screening using 3-D tomosynthesis.
(f) A health carrier shall not establish payment or reimbursement provisions based solely on a participating advanced practice registered nurse's licensure.
IX. The health carrier shall provide to covered persons, in the evidence of coverage, a description for the types of financial arrangements contained in its contracts with participating providers. Such descriptions shall be set forth in clear, understandable language.
X. Every contract between a health carrier and a participating provider shall provide that the health carrier may not remove a health care provider from its network or refuse to renew the health care provider with its network for participating in a covered person's internal grievance procedure or external review.
XI. Every contract entered into after July 1, 2003 between a health carrier and any physician or facility shall contain a provision that ensures that covered persons will have continued access to the provider in the event that the contract is terminated for any reason other than unprofessional behavior. The continued access to providers shall be made available for 60 days from the date of termination of the contract and shall be provided and paid for in accordance with the terms and conditions of the covered person's health benefit plan and the prior contract between a health carrier and a health care provider. Within 5 business days of the contract termination, the health carrier shall provide written notice to affected covered persons explaining their continued access rights.
XII. [Repealed.]
XIII. No health carrier shall interfere with a provider's right to legal representation during contract negotiations by restricting the provider's right to share confidential information with counsel or by refusing to negotiate directly with counsel selected by a provider as long as the provider receives assurance that counsel agrees to keep confidential the information exchanged during the course of negotiations to the same extent the provider is obligated to keep such information confidential.
XIV. Every contract or contract amendment entered into after the effective date of this paragraph between a health care carrier and any provider or facility shall contain a provision stating that no provider employed by a hospital or any affiliate is required or in any way obligated to refer patients to providers also employed or under contract with the hospital or any affiliate. Nothing in this paragraph shall be construed to prohibit health care carriers from providing coverage for only those services which are medically necessary and subject to the terms and conditions of the covered person's policy.
XV. (a) All contracts between a carrier or pharmacy benefit manager and a contracted pharmacy shall include:
(1) The sources used by the pharmacy benefit manager to calculate the drug product reimbursement paid for covered drugs available under the pharmacy health benefit plan administered by the carrier or pharmacy benefit manager.
(2) A process to appeal, investigate, and resolve disputes regarding the maximum allowable cost pricing. The process shall include the following provisions:
(A) A provision granting the contracted pharmacy or pharmacist at least 30 business days following the initial claim to file an appeal;
(B) A provision requiring the carrier or pharmacy benefit manager to investigate and resolve the appeal within 30 business days;
(C) A provision requiring that, if the appeal is denied, the carrier or pharmacy benefit manager shall:
(i) Provide the reason for the denial; and
(ii) Identify the national drug code of a drug product that may be purchased by contracted pharmacies at a price at or below the maximum allowable cost; and
(D) A provision requiring that, if an appeal is granted, the carrier or pharmacy benefits manager shall within 30 business days after granting the appeal:
(i) Make the change in the maximum allowable cost; and
(ii) Permit the challenging pharmacy or pharmacist to reverse and rebill the claim in question.
(b) For every drug for which the pharmacy benefit manager establishes a maximum allowable cost to determine the drug product reimbursement, the pharmacy benefit manager shall:
(1) Include in the contract with the pharmacy information identifying the national drug pricing compendia or sources used to obtain the drug price data.
(2) Make available to a contracted pharmacy the actual maximum allowable cost for each drug.
(3) Review and make necessary adjustments to the maximum allowable cost for every drug for which the price has changed at least every 14 days.
(c) [Repealed.]
(d) [Repealed.]
XVI. No contract between an insurance carrier or pharmacy benefit manager and a contracted pharmacy shall contain a provision prohibiting divulgence to a covered person or the insurance department relative to monetary matters which would prove beneficial in lowering costs to such covered person.
XVII. [Repealed.]
XVIII. Every contract entered into after September 1, 2022 between a health carrier and any health care provider shall contain a provision that requires the health care provider to notify the carrier when the health care provider is no longer accepting new patients. Notification shall take place no more than 30 days after the date the health care provider is no longer accepting new patients.
Source. 1997, 345:1. 1998, 377:3. 1999, 284:1. 2000, 18:14; 198:1. 2002, 207:11. 2003, 284:2, 9. 2005, 161:1. 2007, 195:1. 2009, 252:3, eff. Sept. 14, 2009. 2016, 177:3, eff. Jan. 1, 2017. 2017, 223:1, eff. July 11, 2017; 223:2, eff. May 1, 2018. 2018, 92:1, eff. May 25, 2018; 92:2, eff. June 30, 2020; 164:1, eff. Jan. 1, 2019. 2019, 226:1, eff. Sept. 10, 2019. 2021, 189:5, eff. Aug. 10, 2021; 189:6 eff. Jan. 1, 2025. 2022, 84:1, eff. Jan. 1, 2023. 2024, 306:1, eff. Jan. 1, 2025.
Section 420-J:8-a
420-J:8-a Prompt Payment Required. –
I. (a) Health carriers issuing health benefit plans subject to this chapter shall pay claims submitted by health care providers for services rendered in New Hampshire to covered persons within 30 calendar days upon receipt of a clean non-electronic claim or 15 calendar days upon receipt of a clean electronic claim.
(b) When the health carrier is denying or pending the claim, the carrier shall have 15 calendar days upon receipt of an electronic claim or 30 days upon receipt of a non-electronic claim to notify the health care provider or covered person of the reason for denying or pending the claim and what, if any, additional information is required to adjudicate the claim. Upon the health carrier's receipt of the requested additional information, the health carrier shall adjudicate the claim within 45 calendar days. If the required notice is not provided, the claim shall be treated as a clean claim and shall be adjudicated pursuant to subparagraph (a).
(c) Payment of a claim shall be considered to be made on the date a check was issued or electronically transferred. The health carrier shall mail checks no later than 5 business days after the date a check was issued. Failure to mail a check within 5 business days shall constitute a violation subject to enforcement under RSA 415:20.
(d) The health carrier's failure to comply with the time limits in this section shall not have the effect of requiring coverage for an otherwise non-covered claim. This section shall only apply to payments made on a claims basis and shall not apply to capitation or other forms of periodic payment.
II. In this section:
(a) "Clean claim" means a claim for payment of covered health care expenses that is submitted to a health carrier on the carrier's standard claim form using the most current published procedural codes, with all the required fields completed with correct and complete information in accordance with the carrier's published filing requirements.
(b) "Electronic claim" means the transmission of data for purposes of payment of covered health care services in an electronic data format specified by the health carrier and, if covered by the Health Insurance Portability and Accountability Act (HIPAA), is in such form and substance as to be in compliance with such act.
III. Any initial clean claim submission not paid within the time periods specified in subparagraph I(a) shall be deemed overdue. In that case:
(a) The health carrier shall pay the health care provider or the insured person the amount of the overdue claim plus an interest payment of 1.5 percent per month beginning from the date the payment was due; and
(b) The health care provider may recover from the carrier, upon a judicial finding of bad faith, reasonable attorney's fees for advising and representing a health care provider in a successful action against a carrier for payment of the claim.
IV. Exceptions to the requirements of this section are as follows:
(a) No health carrier shall be in violation of this section for a claim submitted by a health care provider if:
(1) Failure to comply is caused by a directive from a court or a federal or state agency;
(2) The health carrier is in liquidation or rehabilitation or is operating in compliance with a court-ordered plan of rehabilitation; or
(3) The carrier's compliance is rendered impossible due to matters beyond the carrier's control which are not caused by such carrier.
(b) No health carrier shall be in violation of this section for any claim submitted more than 90 days after the service was rendered.
(c) No health carrier shall be in violation of this section while the claim is pending due to a fraud investigation that has been reported to a state or federal agency, or an internal or external review determination pursuant to RSA 420-J:5 or RSA 420-J:5-a-e.
V. The commissioner may assess an administrative fine against any health carrier or may suspend or revoke the license or certificate of authority of any health carrier after determining that the health carrier has established a pattern of overdue payments and that the contemplated enforcement action would not promote the deterioration of the financial condition of an at-risk insurer. Such fine shall not exceed $300,000 per calendar year examined. Nothing in this paragraph shall be construed to alter the commissioner's authority to investigate or take action, including, but not limited to, action pursuant to RSA 415:20, in response to individual instances of noncompliance.
Source. 2000, 274:5; 314:5. 2005, 162:4. 2009, 235:17, eff. Sept. 14, 2009.
Section 420-J:8-b
420-J:8-b Retroactive Denials Prohibited; Exceptions. –
I. In this section, "retroactive denial of a previously paid claim" means any attempt by a health carrier to retroactively collect payments already made to a health care provider with respect to a claim by requiring repayment of such payments, reducing other payments currently owed to the provider, withholding or setting off against future payments, or reducing or affecting the future claim payments to the provider in any other manner.
II. No health carrier shall impose on any health care provider any retroactive denial of a previously paid claim or any part thereof unless:
(a) The carrier has provided the reason for the retroactive denial in writing to the health care provider; and
(b) The time which has elapsed since the date of payment of the challenged claim does not exceed 12 months. The retroactive denial of a previously paid claim may be permitted beyond 12 months from the date of payment only for the following reasons:
(1) The claim was submitted fraudulently;
(2) The claim payment was incorrect because the provider or the insured was already paid for the health care services identified in the claim;
(3) The health care services identified in the claim were not delivered by the physician/provider;
(4) The claim payment was for services covered by Title XVIII, Title XIX, or Title XXI of the Social Security Act;
(5) The claim payment is the subject of an adjustment with a different insurer, administrator, or payor and such adjustment is not affected by a contractual relationship, association, or affiliation involving claims payment, processing, or pricing; or
(6) The claim payment is the subject of legal action.
III. A health carrier shall notify a health care provider at least 15 days in advance of the imposition of any retroactive denials of previously paid claims. The health care provider shall have 6 months from the date of notification under this paragraph to determine whether the insured has other appropriate insurance, which was in effect on the date of service. Notwithstanding the contractual terms between the health carrier and provider, the health carrier shall allow for the submission of a claim that was previously denied by another insurer due to the insured's transfer or termination of coverage.
Source. 2002, 143:4. 2006, 104:4, eff. Aug. 7, 2006. 2018, 317:2, eff. Jan. 1, 2019.
Section 420-J:8-c
420-J:8-c Reimbursement for Providers Waiting for Health Carrier Credentialing Verification. –
I. Pursuant to RSA 420-J:4, I, health carriers issuing health benefit plans subject to this chapter shall pay claims for covered services rendered to covered persons by a health care provider who, at the time of submission of a clean and complete credentialing application, has a valid license from the respective state licensing board and has been credentialed by the hospital, if appropriate. The claim for covered services rendered by the provider applicant shall be paid at the same contracted rate as the credentialed provider:
(a) When covering on-call for another health care provider who is credentialed by the carrier and billed using the name of the credentialed provider; or
(b) Who, at the time of application, is credentialed by the health carrier in another state or is in the health carrier's New Hampshire network based on employment with a particular health care entity.
II. For purposes of RSA 420-J:4 and this section, a health care provider having a valid license shall include all:
(a) Mental health practitioners licensed under RSA 330-A.
(b) Psychologists licensed under RSA 329-B.
Source. 2007, 98:2, eff. Aug. 10, 2007. 2019, 228:5, eff. Sept. 10, 2019. 2025, 161:15, 26, eff. Sept. 13, 2025.
Section 420-J:8-d
420-J:8-d Dependent Coverage. –
I. A policy may, at the election of the carrier, insure, originally or by subsequent amendment, upon application of an adult member of a family who shall be deemed the policyholder, any 2 or more eligible members of that family, including husband, wife, dependent children, or any other person dependent upon the policyholder. In the event a carrier elects to provide coverage for dependent children, the term "dependent child" shall include a subscriber's child by blood or by law, who is under age 26.
I-a. The coverage of any family member insured by such policy, pursuant to paragraph I, who is mentally or physically incapable of earning his or her own living as of the date on which such dependent's status as a covered family member would otherwise expire because of age, shall continue under such policy while such policy remains in force or is replaced by another policy as long as such incapacity continues and as long as such dependent remains chiefly financially dependent on the policyholder or the employee or his or her estate is chargeable for the care of such dependent; provided, that due proof of such incapacity is received by the insurer within 31 days of such expiration date. If such coverage is continued in accordance with this paragraph, such dependent shall be entitled upon the termination of such incapacity to coverage offered by the New Hampshire high risk pool under RSA 404-G.
II. Nothing in this section shall be construed to require:
(a) Coverage for services provided to a dependent before the effective date of this section; or
(b) That an employer pay all or part of the cost of family coverage that includes a dependent as provided pursuant to this section.
III. A subscriber that elects family coverage during any applicable open enrollment period may enroll any dependent eligible pursuant to this section.
IV. Coverage for a dependent provided pursuant to this section shall be provided until the earlier of the following:
(a) The dependent is disqualified for dependent status as set forth in paragraph I of this section;
(b) The date upon which the employer under whose contract coverage is provided to a dependent ceases to provide coverage to the subscriber.
V. Nothing in this section shall be construed to permit a health insurance carrier to refuse an election for coverage by a dependent pursuant to paragraph III, based upon the dependent's prior disqualification pursuant to subparagraph IV(a).
VI. (a) Notice regarding coverage for a dependent as provided pursuant to this section shall be provided to a subscriber:
(1) In the certificate of coverage prepared for subscribers on or about the date of commencement of coverage; and
(2) Within 30 days of the effective date of this section.
(b) Such notice shall include information regarding the required special open enrollment period.
Source. 2007, 352:6. 2009, 235:18. 2010, 243:13, eff. Sept. 23, 2010.
Section 420-J:8-e
420-J:8-e Determining the Fair Value of Certain Health Care Items or Services Provided by Nonparticipating Providers. –
Nonparticipating providers or emergency facilities and health carriers shall have access to a state-based independent dispute resolution (IDR) process for determining the fair value of certain health care items or services as follows:
I. Determination through open negotiation.
(a) With respect to an item or service furnished by a nonparticipating provider or nonparticipating emergency facility to which the prohibition on balance billing in RSA 358-T applies and for which a payment is required to be made by the health carrier under RSA 420-J:8-g or under RSA 420-J:8-h, the provider, facility or health carrier may, during the 30-day period beginning on the day the provider or facility receives an initial payment or a notice of denial of payment from the health carrier regarding a claim for payment for such item or service, initiate open negotiations under this paragraph between such provider or facility and health carrier for purposes of determining, during the open negotiation period, a fair value amount agreed on by the parties for payment, including any cost-sharing, for such item or service. For purposes of this paragraph, the state-based open negotiation period relating to an item or service is the 20-day period beginning on the date of initiation of the negotiations with respect to such item or service.
(b) Each health carrier shall provide to the commissioner a designated point of contact, including his or her email address, for open negotiations, and the commissioner shall publish and update a directory of such designated point of contacts. A provider or facility properly initiates open negotiations by emailing such designated point of contact and providing information sufficient to identify the initial payment or notice of denial of payment at issue.
II. Accessing the state-based IDR process in case of failed negotiations. If open negotiations with respect to an item or service under paragraph I do not result in a determination of an amount of payment for such item or service by the last day of the state-based open negotiation period, the provider or facility may initiate the state-based IDR process by delivering, simultaneously to the commissioner and to the health carrier during the 4-day period beginning on the day after the open negotiation period, a review request notification form containing such information as specified by the commissioner. The date of submission of the review request notification form shall be the date of receipt of a qualifying form by the commissioner.
III. Submission of offers. Not less than 10 days after the date of submission of the review request notification, the provider or facility and health carrier party to such IDR process regarding the fair value of an item or service shall each submit to the IDR entity appointed pursuant to this section:
(a) An offer for a payment amount for such item or service furnished by such provider or facility;
(b) Such information as is requested by the independent review entity relating to such offer; and
(c) Any information relating to the offer deemed by the provider, facility, or health carrier to be relevant to the fair value determination.
IV. Authority to continue negotiations. Under the state IDR process provided for in this section, in the case that the disputing parties agree on a payment amount for the item or service in dispute during the period in which the dispute is under review by the selected IDR entity and before the date on which the selected IDR entity makes its fair value determination, then such agreed amount shall qualify as the fair value amount without the necessity of a fair value determination by the IDR entity. This agreement during the period in which the dispute is before the IDR entity shall not affect the fee that the IDR entity is entitled to collect.
V. Considerations in the fair value determination.
(a) In general, in determining which offer is the payment amount to be applied pursuant to this section as the fair value of items or services rendered, the IDR entity shall consider:
(1) The qualifying payment amount for the item or service furnished; and
(2) Subject to subparagraph (c), information regarding any circumstance described in subparagraph (b), such information as is requested and received by the IDR entity, and any additional relevant information provided by the parties.
(b) In addition to the considerations listed in RSA 420-J:8-e, V(a), the IDR entity shall consider, if such information is provided by either of the parties:
(1) The level of training, experience, and quality and outcomes measurements of the provider or facility that furnished such item or service, such as those endorsed by the consensus-based entity authorized in 42 U.S.C. section 1395aaa.
(2) The market share held by the nonparticipating provider or facility or that of the plan or issuer in the geographic region in which the item or service was provided.
(3) The acuity of the individual receiving such item or service or the complexity of furnishing such item or service to such individual.
(4) The teaching status, case mix, and scope of services of the nonparticipating facility that furnished such item or service.
(5) Demonstrations of good faith efforts, or lack of good faith efforts, made by the nonparticipating provider or nonparticipating facility or the health carrier to enter into network agreements and, if applicable, contracted rates between the provider or facility, as applicable, and the health carrier, as applicable, during the previous 4 plan years.
(c) In determining which offer is the payment to be applied pursuant to this sub-section as the fair value of items or services rendered, the IDR entity shall not consider usual and customary charges, the amount that would have been billed by such provider or facility with respect to such items and services had the provisions of 42 U.S.C. section 300gg-131 or 300gg-132, as applicable, not applied, or the payment or reimbursement rate for such items and services furnished by such provider or facility payable by a public payor, including under the Medicare program under 42 U.S.C. 1395 et seq., under the Medicaid program under 42 U.S.C. 1396 et seq., under the Children's Health Insurance Program under 42 U.S.C. 1397aa et seq., and under the federal TRICARE program.
VI. Batching of items and services.
(a) The provider or facility initiating the IDR process described in this section may batch items and services from more than one episode of care for consideration jointly as part of a single determination by a single independent dispute resolution entity provided that the following requirements are met:
(1) Such items and services to be included in such determination are furnished by the same provider or facility;
(2) Payment for such items and services is required to be made by the same health carrier;
(3) Such items and services are related to the treatment of a similar condition; and
(4) Such items and services were furnished during the 30-day period following the date on which the first item or service included with respect to such determination was furnished or an alternative period as determined by the commissioner, for use in limited situations, such as by the consent of the parties or in the case of low-volume items and services, to encourage procedural efficiency and minimize health carrier and provider administrative costs.
(b) In carrying out subparagraph (a), the commissioner shall provide that, in the case of items and services which are included by a provider or facility as part of a single episode of care, the items and services furnished in that single episode of care may be part of a single fair value determination under this section.
VII. Fair value determination based on written record. In making the fair value determination, the IDR entity shall consider only such written material as is submitted by the parties and shall not engage in ex parte contact with either party.
VIII. Timing of the fair value determination. Not later than 30 days after the submission of offers under paragraph III with respect to a fair value determination for an item or service, the IDR entity shall:
(a) Taking into account the considerations specified in paragraph V, select one of the offers submitted under paragraph III to be the amount of payment for such item or service determined under this section; and
(b) Provide written notification to the provider or facility and the health carrier party to such determination of the offer selected under subparagraph (a).
IX. Effects of determination. The fair value decision of the IDR entity shall be binding on the parties and shall not be subject to re-review except in the case of fraud. The decision shall be enforceable against the health carrier by the commissioner pursuant to the penalty provisions of RSA 420-J:14 and under the enforcement provisions of RSA 417. The fair value dispute resolution process shall not be considered an adjudicative proceeding within the meaning of RSA 541-A, and the decision of the independent dispute resolution entity shall not be subject to rehearing and appeal pursuant to RSA 541 or RSA 400-A:17.
X. Timing of payment of fair value amount.
(a) The health carrier shall make payment to the nonparticipating provider or facility within 30 days after the date on which:
(1) A fair value amount is agreed on by the parties in open negotiations under paragraph I or while the dispute is before the IDR entity as provided in paragraph IV; or
(2) A fair value determination is made by the IDR entity under paragraph VIII.
(b) If the fair value amount is not paid in full within the 30-day period under subparagraph (a), the health carrier shall also be liable to the nonparticipating provider or facility for an interest payment of 5 percent per month, in addition to all other remedies otherwise provided by law. In addition, the nonparticipating provider or facility may recover from the health carrier, upon a judicial finding that the out-of-network rate was not timely paid, reasonable attorney's fees for advising and representing the nonparticipating provider or facility in an action against a carrier for prompt payment of the fair value amount.
XI. Certification and selection of independent dispute resolution entities.
(a) The commissioner shall certify independent dispute resolution entities that:
(1) Make application to the commissioner for certification on a form requiring such information as specified by the commissioner through an insurance department bulletin; and
(2) Demonstrate that they are certified as IDR entities under the federal process set out in 42 U.S.C. section 300gg-111(c)(4) or otherwise meet these federal standards for certification; and
(3) Satisfy such additional requirements established by the commissioner.
(b) The commissioner shall utilize the process set out in 42 U.S.C. section 300gg-111(c)(4)(F) for the selection of an independent dispute resolution entity to adjudicate fair value disputes under this section.
XII. Costs of the independent dispute resolution process.
(a) There shall be no administrative fee charged by the commissioner for administering the independent dispute resolution process.
(b) The commissioner shall establish by rulemaking a fee schedule, which may vary by complexity of the matter in dispute, that independent dispute resolution entities may charge for the review and resolution of disputes with respect to the fair value of unbatched and batched services. To the extent practicable, the fee schedule shall be sufficient to ensure that an adequate number of entities are certified as required for the timely and efficient adjudication of fair value disputes and sufficiently limited to produce a cost-effective option for disputing parties to reach a fair value amount.
(c) Each party participating in a fair value dispute resolution process under this section shall submit, together with its submission of an offer for a payment amount as provided under paragraph III, one half of the fee charged by the certified IDR entity. If any party does not timely submit its half of the IDR entity's fee together with its offer for a payment amount, then the IDR entity shall, without further consideration, select the offer of the party that has paid its half of the fee as the winning offer and notify the parties of the determination as provided in paragraph VIII.
XIII. The commissioner shall make the IDR process set out in this section available, on a case-by-case basis, to providers or facilities that are party to a fair value dispute about items or services to which the prohibition on balance billing in RSA 358-T applies. This option shall include fair value disputes in which one of the parties is a self-funded health plan not otherwise subject to regulation under this chapter only if the self-funded plan has opted into the state IDR program generally, with respect to all subsequent fair value disputes, and consented to be bound by the terms of the process as set out in this section through the submission to the commissioner of a program opt-in form which shall be made available by the commissioner.
XIV. The authority of the commissioner to administer the IDR process set out in this section shall arise on a case-by-case basis with respect to specific items or services as providers or facilities choose to invoke the state IDR process to determine the fair value of that item or service. This section shall constitute a "specified state law" under 42 U.S.C. section 300gg-111(a)(3)(I) contextually with respect to an item or service and only when a provider or facility has invoked the state IDR process with respect to that item or service. This section is not intended to preempt or displace the authority or obligation of the secretary of the federal department of health and human services to administer the federal IDR process as provided under 42 U.S.C. section 300gg-111 whenever the provider or facility to which the prohibition on balance billing in RSA 358-T applies does not choose to invoke the state IDR process.
XV. If a provider or facility that is party to a fair value dispute about items or services to which the prohibition on balance billing in RSA 358-T applies invokes the state IDR process set out in this chapter by submission of a review request notification under paragraph II, then both parties shall be precluded from accessing the federal IDR process under 42 U.S.C. section 300gg-111. If no party to a fair value dispute about items or services to which the prohibition on balance billing in RSA 358-T applies invokes the state IDR process set out in this chapter by submitting a review request notification under paragraph II within the 4-day period following the 20 day state-based open negotiation period, then the federal IDR process under 42 U.S.C. section 300gg-111 shall be available to both parties after the expiration of the federal 30-day open negotiation period as provided in 42 U.S.C. section 300gg-111(c)(1)(B).
XVI. If a party to a fair value dispute about items or services to which the prohibition on balance billing in RSA 358-T applies initiates the state IDR process set out in this chapter by submission of a review request notification under paragraph II, then the disputing parties shall be limited to the state IDR process for determining the fair value of all other items and services that are part of the same episode of care, and both parties shall be precluded from accessing the federal IDR process under 42 U.S.C. section 300gg-111 with respect to all such items or services.
XVII. The commissioner shall enter into a collaborative enforcement agreement with the Centers for Medicare and Medicaid Services (CMS) in order to set up processes and systems in coordination with CMS to resolve potential federal IDR eligibility questions arising from the case-specific applicability of the specified state law created in this chapter.
Source. 2018, 356:2, eff. July 1, 2018. 2020, 27:35, eff. July 21, 2020. 2024, 143:9, eff. Jan. 1, 2025. 2025, 191:1, eff. Sept. 13, 2025.
Section 420-J:8-f
420-J:8-f Non-Covered Dental Services. –
I. No insurer, health care service contractor, health maintenance organization, dental insurer, or any other similar entity, including Delta Dental Plan of New Hampshire Inc., subject to regulation by the insurance department that covers dental services, and no contract or participating provider agreement with a dentist shall require, directly or indirectly, that a dentist who is a participating provider provide services to an enrolled participant at a fee set by, or at a fee subject to the approval of, the regulated entity unless the dental services are covered services.
II. No person providing third party administrator services shall make available for any customers a plan that sets dental fees for providers in its provider network for any services except covered services.
III. In this paragraph "covered services" means dental care service for which reimbursement is available under an enrollee's plan contract, or for which reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.
IV. Fees for covered services shall be set in good faith and shall not be nominal.
Source. 2020, 39:14, eff. Jan. 1, 2021.
Section 420-J:8-g
420-J:8-g Coverage and Payment for Emergency Services Provided by Nonparticipating Providers or Nonparticipating Emergency Facilities. –
I. Each insurer that issues or renews any policy of health insurance providing benefits for emergency services shall cover emergency services provided by a nonparticipating provider or nonparticipating emergency facility in the same manner and without imposing any additional requirements as if the services were provided by a participating provider or participating emergency facility.
II. The patient's cost-sharing for items or emergency services provided by a nonparticipating provider or nonparticipating emergency facility shall be calculated by the health carrier based on the lesser of the qualifying payment amount, the billed amount, or the allowed amount for the item or service.
III. The insurer shall pay the nonparticipating provider of emergency services or nonparticipating emergency facility an amount based on the fair value considerations set out in RSA 420-J:8-e, IV, less any cost-sharing for the services provided.
IV. In the event of a dispute between a nonparticipating provider or facility and an insurer relative to the fair value of an item or service under this section, the commissioner shall make available, as provided in RSA 420-J:8-e, an independent dispute resolution process to determine the fair value payment amount.
Source. 2024, 143:10, eff. Jan. 1, 2025. 2025, 191:22, eff. Sept. 13, 2025.
Section 420-J:8-h
420-J:8-h Coverage and Payment for Services Provided at Participating Facilities by Nonparticipating Providers. –
I. Each health carrier that issues or renews any policy of health insurance shall cover services provided by nonparticipating providers at a participating facility in the same manner and without imposing any additional requirements as if the services were provided by a participating provider.
II. The patient's cost-sharing for items or services provided by a nonparticipating provider at a participating facility shall be calculated by the health carrier based on the lesser of the qualified payment amount, the billed amount, or the allowed amount for the item or service.
III. The health carrier shall pay the nonparticipating provider an amount based on the fair value considerations set out in RSA 420-J:8-e, IV, less any cost-sharing for the services provided.
IV. In the event of a dispute between a nonparticipating provider and a health carrier relative to the fair value of an item or service under this section, the commissioner shall make available, as provided in RSA 420-J:8-e, an independent dispute resolution process to determine the fair value payment amount.
Source. 2024, 143:10, eff. Jan. 1, 2025. 2025, 191:23, eff. Sept. 13, 2025.
Section 420-J:9
420-J:9 Quality Assessment, Quality Improvement, and Reporting. –
I. A health carrier shall:
(a) Establish and maintain a written quality assessment program designed to collect and evaluate information regarding the quality of the health care processes used by the health carrier and the health outcomes of its covered persons.
(b) Establish and maintain a written quality improvement program structured to identify opportunities to improve care, practices that result in improved health care outcomes, problematic utilization patterns, and those providers who may be responsible for either exemplary or problematic patterns of utilization.
II. The quality improvement program shall at a minimum include: a statement of the objectives of the program; a description of how the health carrier will conduct its quality improvement program; the lines of authority and accountability including data collection responsibilities; evaluation tools; performance improvement activities; and an annual effectiveness review.
III. The chief medical officer or clinical director of the health carrier shall have primary responsibility for the quality assessment and quality improvement activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of this chapter relative to quality assessment and quality improvement are met.
IV. A health carrier shall:
(a) Assure that participating providers have an opportunity to participate in developing, implementing, and evaluating the quality assessment and quality improvement programs.
(b) Maintain at its principal office a copy of the quality assessment program and the quality improvement program which shall be available for inspection by the commissioner or designee at any time during the health carrier's regular business hours.
(c) Certify to the commissioner on or before March 1 of each year that its quality assessment program and its quality improvement program meet the requirements of this chapter and any applicable rules.
(d) Notify the commissioner on or before March 1 of each year of its accreditation by any external accrediting agencies and shall provide a contact person and a phone number for consumer phone calls.
Source. 1997, 345:1, eff. Jan. 1, 1998.
Section 420-J:10
420-J:10 Confidentiality of Insurer Records. –
I. Data or information pertaining to the diagnosis, treatment, or health of a covered person obtained from the person or from a provider by a health carrier is confidential and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of this chapter and as allowed by any applicable state or federal law; or upon the express consent of the covered person; or pursuant to statute or court order for the production of evidence or the discovery thereof; or in the event of a claim or litigation between the covered person and the health carrier where the data or information is pertinent, regardless of whether the information is in the form of paper, is preserved on microfilm, or is stored in a computer retrievable form.
II. If any data or information pertaining to the diagnosis, treatment, or health of any enrollee or applicant is disclosed pursuant to paragraph I, the health carrier making this required disclosure shall not be liable for the disclosure or any subsequent use or misuse of the data.
III. A health carrier shall be entitled to claim any statutory privileges against disclosure that the provider who furnished the information to the health carrier is entitled to claim.
IV. The records of the quality assessment program, and the information considered by any quality committee and the records of its actions and proceedings shall be confidential and not subject to subpoena or order to produce except in proceedings before the department or other appropriate state licensing or certifying agency, or in an appeal, if permitted, from the quality committee's findings or recommendations. This section shall not be construed to affect the confidentiality of any other proprietary record of a health carrier.
Source. 1997, 345:1, eff. Jan. 1, 1998.
Section 420-J:11
420-J:11 Confidentiality of Insurance Department Records. –
All information, documents and copies thereof obtained by or disclosed to the commissioner or any other person in the course of an examination or investigation made pursuant to RSA 400-A:37, and, unless otherwise provided in this chapter, all information reported and maintained pursuant to this chapter shall be given confidential treatment and shall not be made public by the commissioner or any other person, except to insurance departments of other states, unless the commissioner after consultation with the affected parties, determines that the interest of policyholders, shareholders, or the public will be served by the publication thereof, in which event the commissioner may disclose all or any part thereof in such manner as the commissioner may deem appropriate.
Source. 1997, 345:1, eff. Jan. 1, 1998.
Section 420-J:12
420-J:12 Rulemaking Authority. –
The commissioner may adopt such rules, under RSA 541-A, and issue such orders as may be necessary to carry out the purposes and provisions of this chapter.
Source. 1997, 345:1, eff. Jan. 1, 1998.
Section 420-J:13
420-J:13 Severability. –
If any provision of this chapter or the application thereof to any person or circumstance is held invalid, the invalidity does not affect other provisions or applications of the chapter which can be given effect without the invalid provisions or applications, and to this end the provisions of this chapter are severable.
Source. 1997, 345:1, eff. Jan. 1, 1998.
Section 420-J:14
420-J:14 Penalties. –
Any health carrier or other organization violating any of the provisions of this chapter may be subject to an administrative fine not to exceed $2,500 per violation. The commissioner may also suspend or revoke the certificate of authority or license of a health carrier or other organization for any violation of this chapter or the failure to comply with an order of the commissioner issued under this chapter.
Source. 1997, 345:1, eff. Jan. 1, 1998.
Substance Use Disorders
Section 420-J:15
420-J:15 Definitions. –
In this subdivision:
I. "ASAM criteria" means the latest edition of the Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, developed by the American Society of Addiction Medicine.
II. "Clinical stabilization services" means 24-hour clinically-managed post-withdrawal management treatment for adults or adolescents which may include intensive education and counseling regarding the nature of addiction and its consequences, relapse prevention, outreach to families and significant others, and after-care planning, for individuals beginning to engage in recovery from addiction.
III. "Short-term inpatient withdrawal management" means 24-hour medically-supervised addiction treatment for adults or adolescents provided in medically-managed or medically-monitored inpatient facilities that provide evaluation and withdrawal management and which may include biopsychosocial assessment, individual and group counseling, psychological educational groups, and discharge planning.
IV. "Substance use disorder services" means health care services that are provided to a covered person as treatment for an addictive substance-related condition, not including treatment for any condition related to tobacco use.
Source. 2016, 2:11, eff. Jan. 1, 2017; 275:1, eff. Jan. 1, 2017 at 12:01 a.m.
Section 420-J:16
420-J:16 Levels of Care Criteria; Attestation. –
I. Whenever substance use disorder services are a covered benefit under a health benefit plan subject to this chapter, the health carrier providing such benefits shall rely upon ASAM criteria when determining medical necessity and developing utilization review standards for levels of care for substance use disorder services.
II. On January 1 of each year, each health carrier that provides coverage for substance use disorder services shall file with the commissioner an annual attestation of compliance with this subdivision.
Source. 2016, 2:11, eff. Jan. 1, 2017.
Section 420-J:17
420-J:17 Prior Authorization. –
I. Whenever substance use disorder services are a covered benefit under a health benefit plan subject to this chapter, no prior authorization shall be required for the first 2 routine outpatient visits of an episode of care by an individual for assessment and care with respect to a substance use disorder.
II. Whenever substance use disorder services are a covered benefit under a health benefit plan subject to this chapter, no prior authorization shall be required for short-term inpatient withdrawal management and clinical stabilization services for up to 24 hours, when prescribed by a clinician trained in the use and application of the ASAM criteria; provided, that the facility notifies the patient's health carrier as soon as practicable after admission of the patient. If the facility fails to notify the patient's health carrier as soon as practicable after admission of the patient, the facility shall be financially responsible for the costs of any services provided by the facility to the patient.
III. Alternatively, a carrier may require prior authorization for the services described in paragraph II, but only if the carrier has a medical clinician or licensed alcohol and drug counselor available on a 24-hour hotline to make the medical necessity determination and assist with placement at the appropriate level of care, and the carrier provides a prior authorization decision as soon as practicable after receipt from the treating clinician of the clinical rationale consistent with the ASAM criteria, but in no event more than 6 hours of receiving such information; provided that until such hotline determination is made, coverage for substance use disorder services shall be provided at an appropriate level of care consistent with the ASAM criteria, as defined in RSA 420-J:15, I.
IV. If an insurance policy does not require prior authorization for short-term inpatient withdrawal management services or clinical stabilization services, paragraphs II and III shall not apply.
V. Nothing in this section shall be construed to require coverage for services provided by a non-participating provider.
Source. 2016, 2:11, eff. Jan. 1, 2017; 275:2, eff. Jan. 1, 2017 at 12:01 a.m.
Section 420-J:18
420-J:18 Authorization for Medication-Assisted Treatment. –
Whenever substance use disorder services are a covered benefit under a health benefit plan subject to this chapter, a health carrier shall:
I. Be required to offer at least one medication-assisted treatment therapy option approved by the federal Food and Drug Administration for treatment of substance use disorders without a requirement for prior authorization.
II. Not require a renewal of a prior authorization for a medication-assisted treatment therapy for treatment of substance use disorders more frequently than once every 12 months.
Source. 2017, 185:1, eff. Aug. 28, 2017. 2020, 39:52, eff. Sept. 27, 2020.
Section 420-J:19
420-J:19 Medication Synchronization. –
I. An individual or group health insurance plan or policy providing prescription drug coverage in New Hampshire, shall permit and apply a prorated, daily cost-sharing rate to covered prescriptions for a chronic condition that are dispensed by an in-network pharmacy for less than a 30-day supply if the prescriber and pharmacist determine the fill or refill to be in the best interest of the patient for the management or treatment of a chronic, long-term care condition and the patient requests or agrees to less than a 30-day supply for the purpose of synchronizing the patient's medications. For the purposes of this paragraph, the insured's or enrollee's maintenance prescription drugs to be synchronized shall meet all of the following requirements:
(a) They are covered by the policy, certificate, or contract described in this chapter.
(b) They are used for the management and treatment of a chronic, long-term care condition and have authorized refills that remain available to the insured or enrollee.
(c) Except as otherwise provided in this paragraph, they are not a controlled substance included in schedules II-V.
(d) They meet all utilization management requirements specific to the maintenance-prescription drugs at the time of the request to synchronize the insured's or enrollee's multiple, maintenance-prescription drugs.
(e) They are of a formulation that can be effectively split over required short-fill periods to achieve synchronization.
(f) They do not have quantity limits or dose-optimization criteria or requirements that will be violated when synchronizing the insured's or enrollee's multiple, maintenance-prescription drugs.
II. The plan or policy described in paragraph I shall apply a prorated, daily cost-sharing rate for maintenance-prescription drugs that are dispensed by an in-network pharmacy for the purpose of synchronizing the insured's or enrollee's multiple, maintenance-prescription drugs.
III. The plan or policy described in paragraph I shall not reimburse or pay any dispensing fee that is prorated. The insurer shall only pay or reimburse a dispensing fee that is based on each maintenance-prescription drug dispensed.
IV. A synchronization shall only occur once per year per maintenance-prescription drug.
Source. 2018, 103:2, eff. Jan. 1, 2019.
Reimbursement for Ground Ambulance Services
Section 420-J:20
420-J:20 Definitions. –
In this subdivision:
[Paragraph I repealed by 2025, 262:2, I, effective January 1, 2028.]
I. "Enrolling ground ambulance provider" means a ground ambulance provider who is pursuing in good faith the contracting process for becoming a participating ground ambulance provider with specified health carriers during the period between January 1, 2026, and December 30, 2027, and who has filed with the commissioner a written declaration to that effect on a form provided by the commissioner.
II. "Ground ambulance provider" means a public or private organization licensed by the department of safety under RSA 153-A:10 to provide ground ambulance emergency medical services or the transportation of patients upon any public way of the state.
III. "Ground ambulance services" means:
(a) The rendering of medical treatment and care at the scene of a medical emergency or while transporting a patient from the scene to an appropriate health care facility or behavioral health emergency services provider when the services are provided by one or more ground ambulance vehicles designed for this purpose and licensed by the department of safety under RSA 153-A:10; and
(b) Ground ambulance transport between hospitals or behavioral health emergency services providers, hospitals, or behavioral health emergency services providers and other health care facilities or locations, and between health care facilities when the services are medically necessary and are provided by one or more ground ambulance vehicles designed for this purpose and licensed by the department of safety under RSA 153-A:10.
IV. "Nonparticipating ground ambulance provider" means a ground ambulance provider that is acting within the scope of practice for ground ambulance providers as set out in RSA 153-A, that does not have a contractual relationship directly or indirectly with a health carrier, and that is not an enrolling ground ambulance provider.
V. "Participating ground ambulance provider" means a ground ambulance provider that is a "participating provider" as defined in RSA 420-J:3.
Source. 2025, 262:1, eff. July 31, 2025.
Section 420-J:21
420-J:21 Rate Schedule Established for Certain Ground Ambulance Providers. –
I. There is hereby established a rate schedule applicable to all health carriers doing business in the state to reimburse participating and enrolling ground ambulance providers.
[Paragraph I(a) repealed by 2025, 262:2, II, effective January 1, 2028.]
(a) Beginning January 1, 2026, through December 31, 2027, participating and enrolling ground ambulance providers shall be reimbursed for ambulance services at a temporary rate schedule of 3.25 times the Medicare rate that is current as of the date of service.
(b) Beginning January 1, 2028, participating ground ambulance providers shall be reimbursed for ambulance services at a rate established by the commissioner. The commissioner shall adopt rules under RSA 541-A with an effective date of January 1, 2028, that establish a statewide, cost-based rate schedule for health carriers to use in reimbursing participating ground ambulance providers that implements the rate schedule recommended by the independent accounting and actuarial expert retained pursuant to RSA 420-J:26.
(c) Beginning January 1, 2029, and annually thereafter, the commissioner shall adjust the participating ground ambulance provider rate for inflation using the general consumer price index as reported by the United States Bureau of Labor Statistics. The commissioner shall publish the updated rate by bulletin before January 1 each year.
II. Nothing shall prevent health carriers and ground ambulance providers from voluntarily negotiating an alternative agreed upon rate schedule.
III. Health carriers may apply cost sharing for ambulance services.
IV. For the purpose of determining cost sharing amounts, the rates established in this section shall be considered the allowed amount.
V. Ambulance providers shall be responsible for collecting any cost sharing associated with the ground ambulance services.
Source. 2025, 262:1, eff. July 31, 2025.
Section 420-J:22
420-J:22 Rate Schedule Established for Nonparticipating Ground Ambulance Providers. –
Beginning on January 1, 2026, nonparticipating ground ambulance providers shall be reimbursed by health carriers at the carrier's nonparticipating rate or at the Medicare rate that is current as of the date of service, whichever is higher.
Source. 2025, 262:1, eff. July 31, 2025.
Section 420-J:23
420-J:23 Standardized Ground Ambulance Provider Contract. –
I. The commissioner shall issue a bulletin no later than December 31, 2025, establishing a standardized ground ambulance provider contract template that includes a standardized format and language for contracts between health carriers and ground ambulance providers.
II. Once published by bulletin, all health carriers shall offer ground ambulance providers a standardized ground ambulance contract that incorporates the template established by the commissioner. The health carrier's standardized contract shall be offered to any ground ambulance provider that is qualified and willing to meet the terms and conditions of the standardized ground ambulance provider contract.
III. Nothing shall prevent health carriers and ground ambulance providers from voluntarily negotiating a contract that varies in any respect from the standardized contract.
Source. 2025, 262:1, eff. July 31, 2025.
Section 420-J:24
[RSA 420-J:24 repealed by 2025, 262:2, III, effective January 1, 2028.]
420-J:24 Contract Negations between Ambulance Providers and Health Carriers. –
I. Beginning January 1, 2026, and continuing through December 31, 2027, enrolling ground ambulance providers shall be entitled to the provider rate specified in RSA 420-J:21, I(a) as long as they continue to work in good faith towards executing a contract.
II. If a ground ambulance provider fails to actively engage in the contracting process for a period of 60 days, the ambulance provider shall no longer be considered an enrolling ground ambulance provider. Failure to actively engage in the contracting process shall include, but is not limited to, failure to respond to requests by the health carrier for information and failure to sign necessary documents.
III. Health carriers shall act upon and finalize the contracting process within 45 calendar days of receipt of all necessary documents and information required to execute the contract.
Source. 2025, 262:1, eff. July 31, 2025.
Section 420-J:25
[RSA 420-J:25 repealed by 2025, 262:2, IV, effective January 1, 2028.]
420-J:25 Temporary Maintenance of a Registry of Providers Who Qualify as an Enrolling Ground Ambulance Provider. –
I. No later than December 31, 2025, the commissioner shall publish through bulletin a written contract negotiation initiation form that shall be used by ground ambulance providers to initiate contract negotiations with specified health carriers and to initially qualify as an enrolling ground ambulance provider with respect to the specified health carriers.
II. A ground ambulance provider must submit the form to the department and to the specified health carriers in order to be eligible for the status of an enrolling ground ambulance provider with respect to those carriers.
III. During the period between January 1, 2026, and December 31, 2027, the insurance department shall maintain a list on its website of ambulance providers who qualify as an enrolling ground ambulance provider with respect to a particular carrier.
IV. If the commissioner finds that a ground ambulance provider has failed to engage in the contracting process with respect to a health carrier, the commissioner shall update the list to reflect that the ambulance provider no longer qualifies as an enrolling ground ambulance provider with respect to that carrier.
Source. 2025, 262:1, eff. July 31, 2025.
Section 420-J:26
420-J:26 Requiring an Independent Study by an Accounting and Actuarial Expert of Ground Ambulance Costs in the State and the Establishment of a Cost-Based Reimbursement Schedule for Participating Ground Ambulance Service Providers. –
I. Beginning on the effective date of this section, the commissioner shall oversee the process provided for in this section of contracting with an independent accounting and actuarial expert to conduct a study of the costs incurred by ground ambulance providers related to the provision of ground ambulance services in the state. Costs shall include the cost of pre-hospital care and the cost of sustaining a reasonable operating margin in support of the expectation that ground ambulance providers in the state maintain readiness to meet demand for services. Cost estimates shall be based on the assumption that services shall be provided in a reasonably cost-effective manner.
II. The commissioner of the department of safety shall collaborate with the commissioner in collecting cost surveys from ground ambulance providers in the state. These surveys may either be designed by the accounting and actuarial expert or may be adopted by the expert from the medicare ground ambulance data collection system cost reports. The commissioner of the department of safety shall have authority to enforce this reporting requirement upon ground ambulance providers under the general supervision and specific enforcement authority conferred by RSA 153-A and shall work with the commissioner to set a deadline for ground ambulance providers to submit their cost reports that is sufficient to facilitate the completion of the study and report provided for in this section in a timely manner.
III. The independent accounting and actuarial expert shall submit all cost data submitted by ground ambulance providers to rigorous data validation and auditing procedures and shall verify that the ground ambulance provider has used proper cost allocation methods, including when fire and ambulance services are provided by the same entity. The commissioner of the department of safety shall have authority under the general supervision and specific enforcement authority conferred by RSA 153-A to enforce compliance by ground ambulance providers with data validation and auditing of cost reports. The commissioner of the department of safety shall work with the commissioner to set a deadline for ground ambulance providers to comply with data validation and auditing requirements that is sufficient to facilitate the completion of the study and report provided for in this section in a timely manner.
IV. If a ground ambulance provider fails to cooperate with cost data submission requirements or with requirements to facilitate data validation or cost report auditing requirements, then that provider shall lose access to the temporary rate schedule established for enrolling and participating ground ambulance providers in RSA 420-J:21, and health carriers shall be required to reimburse such providers at their nonparticipating rate or at the Medicare rate that is current as of the date of service, whichever is higher. During the period of the cost study, the commissioner shall maintain a list that shall be made available to health carriers doing business in the state that includes all ground ambulance providers who have been determined by the commissioner to have failed to cooperate with cost data submission requirements or with requirements to facilitate data validation or cost report auditing requirements.
V. If an analytical sample of audited cost reports is utilized by the independent expert that is obtained from a subset of ground ambulance providers in the state, then the most appropriate statistical methods shall be used to ensure that the analytical sample is appropriately normalized and adequately representative of the general population of ground ambulance providers doing business in the state.
VI. Based on the information provided through the cost reports, the independent accounting and actuarial expert shall be directed to summarize the cost information collected and to derive a statewide cost-based rate schedule appropriate for health carriers to use in reimbursing participating ground ambulance providers. The schedule may vary based on geographic region. Reimbursement under the schedule shall be designed to cover the costs attributable to the provision of covered services assuming that all public and commercial ground ambulance payers in the state are paying at the same rate. The independent accounting and actuarial expert shall produce a final report by June 30, 2027, which shall include the expert's recommended cost-based reimbursement schedule for participating ground ambulance providers and which shall detail the methodology used to calculate ground ambulance costs in the state and such other supplemental information as shall be directed by the commissioner. The commissioner shall assist the independent expert as necessary to complete the study, the rate schedule, and the report in a timely manner.
VII. Prior to the completion of its work on June 30, 2027, the independent accounting and actuarial expert shall also advise the commission on improving the ground ambulance services financing and delivery system established in RSA 153-A:38 on the feasibility and advisability of applying for a waiver under Section 1115A of the Social Security Act to enter into an all-payer model agreement for ground ambulance services in the state to implement a uniform, cost-based reimbursement schedule for ground ambulance services that includes Medicare, Medicaid, and all commercial payers and that builds upon the mandatory participating rate schedule and the cost study conducted under this section.
VIII. The cost study required under this section shall be funded in an amount up to $400,000 out of funds as provided in RSA 400-A:15, IV.
Source. 2025, 262:1, eff. July 31, 2025.