Medicare Managed Care Manual, Chapter 4, § 10.16
May 23, 2020 4:08 pm“…if the plan approved the furnishing of a service through an advance determination of coverage, it may not deny coverage... View more
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Mo. Rev. Stat. §376.1210(1)
October 15, 2021 5:15 am(1) Each entity offering individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service... View more
Mo. Rev. Stat. §376.1361(13)
October 15, 2021 5:29 am(13) If an authorized representative of a health carrier authorizes the provision of health care services, the health carrier shall... View more
Mo. Rev. Stat. §376.1361(2)
October 15, 2021 5:14 am(2) Any medical director who administers the utilization review program or oversees the review decisions shall be a qualified health... View more
Mo. Rev. Stat. §376.1363(2)
October 15, 2021 5:16 am(2) For determinations, a health carrier shall make the determination within thirty-six hours, which shall include one working day, of... View more
Mo. Rev. Stat. §376.1363(5)
October 15, 2021 5:30 am(5) A written notification of an adverse determination shall include the principal reason or reasons for the determination, including the... View more
Mo. Rev. Stat. §376.1367(1)
October 15, 2021 5:13 am(1) A health carrier shall cover emergency services necessary to screen and stabilize an enrollee, as determined by the treating... View more
Mo. Rev. Stat. §376.1367(4)
October 15, 2021 5:11 am(4) When an enrollee receives an emergency service that requires immediate post evaluation or post stabilization services, a health carrier... View more
Mo. Rev. Stat. §376.383(6)(1)
October 15, 2021 5:15 am(6)(1) If the health carrier has not paid the claimant on or before the forty-fifth processing day from the date... View more
Mo. Rev. Stat. §376.384(1)(3)
October 15, 2021 5:30 am(1) All health carriers shall: (3) Not request a refund or offset against a claim more than twelve months after... View more