Section
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Obligation
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Start Date
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7.1
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Automated Adjudication
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7/15/05
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7.2
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Increased Internet and Clearinghouse Functionality
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7/15/05
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7.3
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Availability of Fee Schedules and Scheduled Payment Dates - Complete Fee Information
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Final Order Date + 12 months
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7.3
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Availability of Fee Schedules and Scheduled Payment Dates - Up To 100 CPT Codes
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Final Order Date
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7.4
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Investments in Initiatives to Improve Provider Relations
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7/15/05
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7.5
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Reduced Precertification Requirements - Posting on Provider Website
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Final Order Date + 3 months
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7.5
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Reduced Precertification Requirements -Proposals to Self-Insured Plans
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Contracts Issued or Renewed After Final Order Date
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7.6
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Greater Notice of Policy and Procedure Changes
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Final Order Date
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7.7
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Initiatives to Reduce Claim Resubmissions
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7/15/05
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7.8,
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Disclosure of and Commitments Concerning Claims Payment Practices
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---
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7.8(b)
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Consistency of Claim Payment Practices
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Final Order Date + 12 months
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7.8(d)
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Disclosure of Significant Edits on Provider Website
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Final Order Date + 6 months (or as soon thereafter as practicable)
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7.8(d)(i)
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Publish Customized Edits on Provider Website
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Final Order Date + 6 months (or as soon thereafter as practicable)
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7.8(d)(ii)
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Commitments regarding Submission of Clinical Information
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Final Order Date
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7.8(d)(iii)
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Disclosures regarding Modifiers 25 and 59
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Final Order Date + 6 months
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7.9
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Physician Advisory Committee
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---
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7.9(a)
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Establishment of Physician Advisory Committee
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The later of the Final Order Date + 3 months or the selection of the members of the Physician Advisory Committee in accordance with § 7.9(b)
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7.9(b)
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Selection of Members by Company
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9/13/05
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7.9(b)
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Selection of Members by Representative Plaintiffs
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9/13/05
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7.9(b)
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Selection of Remaining Members
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11/12/05
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7.10
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New Dispute Resolution Process for Physician Billing Disputes
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---
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7.10 (a)
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Establishment of Billing Dispute External Review Board
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Final Order Date + 4 months
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7.10(d)
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Selection of the BDERB Members
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11/12/05
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7.11
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Determinations Related to Medical Necessity and Experimental or Investigational Nature of Proposed Services
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---
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7.11(a)
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Procedures regarding Initial Determinations
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Final Order Date
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7.11(b)(ii)
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Establishment of Internal and External Review Processes
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Final Order Date + 12 months
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7.12
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[Intentionally Left Blank]
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---
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7.13
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Participation in Company's Network
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---
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7.13(a)
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Credentialing of Physicians
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Final Order Date + 6 months
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7.13(b)
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General Commitments regarding All Products Clauses
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Final Order Date
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7.13(b)
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Notice to Participating Physicians in Standard Prudent Buyer Plan of Right to Opt Out
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Effective Date + 60
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7.13(c)
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Termination Without Cause
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Final Order Date
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7.13(d)
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Class Member Refusal to Accept New Patients
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Final Order Date
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7.14
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Fee Schedule Changes
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---
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7.14(a)
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Establishing Standard Fee Schedules
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Final Order Date
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7.14(a)
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Limitations regarding Reduction of Fee Schedules
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January 1 of the Year Following the Effective Date
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7.14(b)
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Payment Rules for Injectibles, DME, and Review of New Technology
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Final Order Date
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7.14(c)
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Usual, Reasonable, and Customary Appeals
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Final Order Date + 3 months
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7.14(d)
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Usual, Reasonable, and Customary Determinations
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Final Order Date + 3 months
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7.15
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[Intentionally Left Blank]
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7.16
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Application of Clinical Judgment
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---
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7.16(a)
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Medical Necessity Definition - Current Agreements
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Final Order Date
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7.16(a)
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Medical Necessity Definition - Future Agreements
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Agreements Issued After Final Order Date
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7.16(a)
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Adverse Determination Denial Rate
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For the calendar year beginning after the Final Order Date
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7.16(b)
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Policy Issues Involving Clinical Judgment
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Final Order Date
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7.16(c)
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Consideration of Administrative Exemption Program
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Final Order Date + 6 months
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7.17
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Billing and Payment
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---
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7.17(a)
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Time for Submission of Claims
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Final Order Date
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7.17(b)
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Claims Submission (re: acceptance of certain forms and submissions of Clinical Information)
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Final Order Date
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7.18
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Timelines for Processing and Payment of Complete Claims
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7.18(a)
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30 Day Period for Processing and Payment of Complete Claims
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Final Order Date + 9 months
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7.18(a)
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15 Day Period for Processing and Payment of Electronically Submitted Complete Claims
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Effective Date + 1 year
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7.18(b)-(d)
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Timing of Payment for Complete Claims and Payment of Interest
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Final Order Date + 9 months
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7.18(e)
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Commitments regarding Claim Handling
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Final Order Date + 9 months
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7.19
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No Automatic Downcoding of Evaluation and Management Claims
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Final Order Date
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7.20
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Bundling and Other Computerized Claim Editing
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---
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7.20(a)-(h)
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Modifications to Payment Policies
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Final Order Date + 9 months
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7.20(i)
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Updating Claims Editing Software
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Final Order Date + 6 Months (or as soon thereafter as practicable)
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7.21
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EOB and Remittance Advice Content
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---
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7.21(a)
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Content of EOB Forms
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Final Order Date + 6 months (or as soon thereafter as practicable)
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7.21(a)
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Content of Remittance or Similar Forms
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Final Order Date + 6 months (or as soon thereafter as practicable)
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7.22
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Overpayment Recovery Procedures
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Final Order Date
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7.23
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Improve Accuracy of Eligibility Information
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Final Order Date
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7.24
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Responses to Physician Inquiries
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7/15/05
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7.25
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Confirmation of Medical Necessity
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Final Order Date
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7.26
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Electronic Connectivity
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7/15/05
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7.27
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Information about Physicians Provided by Company
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Final Order Date
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7.28
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Capitation and Physician Organization Specific Issues
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---
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7.28(a)
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Capitation Reporting
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Final Order Date + 120 days
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7.28(b)
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Payments for Plan Members under Capitation Who Do Not Select PCP at Time of Enrollment
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Final Order Date + 120 days
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7.29
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Miscellaneous
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---
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7.29(a)
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No "Gag Clauses"
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Final Order Date
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7.29(b)
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Ownership of and Access to Clinical Information
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7/15/05
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7.29(c)
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Arbitration
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Final Order Date
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7.29(d)
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Impact on Standard Form Agreements and Individually Negotiated Contracts
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---
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§ 7.29(d)(i)
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Standard Form Agreements
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Final Order Date
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§ 7.29(d)(ii)
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Current Individually Negotiated Contracts
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7/15/05
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§ 7.29(d)(iii)
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Future Individually Negotiated Contracts
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7/15/05
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7.29(e)
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Impact on Covered Services
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Final Order Date
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7.29(e)
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Recommendation to Self-Insured Plans
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Contracts Issued or Renewed After Final Order Date
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7.29(f)
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Privacy of Records
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7/15/05
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7.29(g)
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Pharmacy Risk Pools
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Final Order Date
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7.29(h)
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"Stop Loss" Coverage
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Final Order Date
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7.29(i)
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Pharmacy Provisions
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Final Order Date
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7.29(j)
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Restrictive Endorsements
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7/15/05
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7.29(k)
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Scope of Company's Responsibilities
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---
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7.29(k)(i)
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Future Contracts with Delegated Entities
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Final Order Date
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7.29(k)(ii)
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Application to Health Link
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Final Order Date
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7.29(k)(iii)
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Application to Blue Card Program
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Final Order Date
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7.29(k)(iv)
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BCBSA Rules and Regulations
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Preliminary Approval Date
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7.29(k)(v)
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Impact of Settlement(s) in Thomas
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Final Order Date
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7.29(l)
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Copies of Contracts
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Final Order Date
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7.29(m)
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State and Federal Laws and Regulations
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7/15/05
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7.29(n)
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Modification of Means of Disclosure
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7/15/05
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7.29(o)
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Limitations on Obligations of Non-Participating Physicians
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7/15/05
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7.29(p)(i)
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Limitation on Rental Networks - Disclosures on Provider Websites
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Final Order Date + 3 months
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7.29(p)(ii)
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Limitation on Rental Networks - Commitments Regarding Use of Rental Networks or Discounted Fee Schedules
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Final Order Date + 3 months
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7.29(q)
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Effect of Assignment of Benefits
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7/15/05
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7.31
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Estimated Value of Section 7 Initiatives
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---
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7.32
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Force Majeure
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7/15/05
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7.33
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Mental Health and Substance Abuse Provisions
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---
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7.33(a)
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Medical Necessity Definition - Current Agreements
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Final Order Date
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7.33(a)
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Medical Necessity Definitions - Future Agreements
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Agreements Issued After Final Order Date
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7.33(b)
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Listing of Participating Psychiatrists; Referrals
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Final Order Date
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7.33(c)
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Payment for Medically Necessary Covered Services
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Final Order Date
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7.33(d)
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"Prudent Lay Person" Laws
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Final Order Date
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7.33(e)
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Posting of Authorization Form
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Final Order Date
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7.34
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Annual Compliance Reporting
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Final Order Date
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