e. Insurer's may not engage in obstructing a patient's ability to obtain effective treatment as ordered by the treating physician, in way.
f. Insurers may not delay treatment by requiring patient's to obtain further testing, consult other physician's and/or specialists, or requiring or recommending the trial of a less expensive treatment, supplies, or equipment.
g. Insurer's may not exceed three business days in the approval of treatment, supplies, or equipment required for treatment, make every effort to act in the best interest of patient care, document such actions taken to act in the best interest of patient care, and provide such documentation to the patient, provider, and ordering physician within five business days upon their verbal or written request. Failure to comply with prior authorization deadline of three business days will result in the forfeiture of deductible and co-payment, or a penalty of $100.00 if coverage is 100% for each day exceeding the five day requirement of submission of documented actions taken to act in the best interest of patient care, and shall be paid to the beneficiary.
h. Insurers must require a physician's prescription, a letter of medical necessity, but may not require copies of patients confidential medical records, history and physical, or any medical records that may violate a patient's right to privacy in order to approve coverage. Insurers must require the physician's letter of medical necessity to include diagnosis, and a treatment plan specific to each patient's needs, lifestyle, and ability to apply treatment as ordered, and shall include risks if disease is not treated effectively, and prognosis with effective treatment.
i. Insurers may not deny coverage due to an assumption that the patient "may not be compliant", or require a "equipment trial period to prove efficacy or to determine compliance".
j. Insurers may not exceed twenty-five days upon receipt of a clean claim, or otherwise pay the claim at the full amount billed plus one-half times the amount billed for every thirty days the claim is overdue to be included in the payment of the claim to the provider, not through a separate process and department.
Insurers shall not engage in negotiating payment or reimbursement in contracting that will reimburse less than Medicare allowable, unless it is to the negotiated payment is due to an "early payment" discount, in which case payment to provider must be received by the provider with the agreed upon, pre-negotiated "early payment" deadline. Insurers shall participate in early payment discounted negotiation and submit payment based on early payment negotiated contract when the patient is required according to the policy to pay any portion of their treatment, supplies, or equipment
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