Section 031-365-6 - Responsibilities of Carriers1. Upon receipt of a claim for covered emergency services rendered by an out-of-network provider, a carrier shall:A. pay the claim based on an allowable charge calculated in accordance with paragraph B, unless the carrier and provider negotiate a different amount or the patient knowingly elected to obtain the services from an out-of-network provider. The carrier shall pay the allowable charge to the provider, subject to the following adjustments: (1) Payment shall be made net of the coinsurance, copayment, deductible, and any other out-of-pocket expense for which the enrollee is responsible under subsection 3;(2) To the extent that the enrollee has paid the provider more than the cost sharing required by subparagraph (1), the carrier shall pay the excess to the enrollee and deduct that amount from the payment otherwise due to the provider;(3) Payment shall be made net of any amounts already paid by the carrier; and(4) If the carrier is a secondary payer, the enrollee's and carrier's responsibility shall be reduced as called for by applicable coordination of benefits procedures;B. determine the total amount the provider is entitled to receive for health care services rendered. The carrier's determination of median network rates shall be based on the CPT code for the claim and the geographic rating area in which the service was rendered, unless the carrier determines that the available data are insufficient or otherwise inapplicable, in which case the carrier, subject to the process of negotiation and IDR review, may use a broader geographic area or bundle of CPT codes. The provider's allowable charge shall be the greater of: (1) the carrier's median network rate paid for the service by a similar provider in the geographic area in which the service was rendered; and(2) the median network rate paid by all carriers for that health care service by a similar provider in the geographic area in which the service was rendered as determined by the all-payer claims database maintained by the Maine Health Data Organization or, if Maine Health Data Organization claims data is insufficient or otherwise inapplicable, another independent medical claims database specified by the Superintendent after consulting with interested parties.C. give notice to the provider, in a form and manner prescribed by the Superintendent, specifying the carrier's allowable charge for the service, and describing how the provider may initiate the IDR process if the carrier and provider are unable to reach agreement within 30 days;D. if the carrier pays an amount less than the provider's charge, provide the enrollee with notice which shall explain that the enrollee shall incur no greater out-of-pocket costs for the services than the enrollee would have incurred with a network provider. The carrier may provide this notice on or with the explanation of benefits required under 24-A M.R.S. §4303(13); andE. direct the enrollee to contact the carrier if the provider bills the enrollee for the out-of-network service for more than the amount indicated as the enrollee's responsibility on the carrier's explanation of benefits.2. A carrier shall prominently post on its website the following information regarding surprise bills and bills for emergency services rendered by out-of-network providers, and include the same information in disclosure materials provided to enrollees: A. a description of what constitutes a surprise bill;B. an explanation of which surprise bills are eligible for the IDR process;C. a description of the IDR process;D. information on how an out-of-network provider may submit a dispute for resolution by an IDRE.3. A carrier shall ensure that the enrollee does not incur any greater out-of-pocket costs for the services than the enrollee would have incurred with a provider charging the carrier's median network rate. The carrier may not increase the enrollee's coinsurance if negotiation or IDR results in an increase in the applicable network rate.4. If an IDRE directs a carrier to engage in negotiations with an out-of-network provider, the IDRE shall specify a time period for negotiation, not to exceed ten business days, and the parties shall negotiate in good faith. If a settlement is reached, the carrier shall notify the IDRE of the settlement within two business days and shall make any additional payment to the provider within thirty days. If a settlement is not reached or the parties agree that a settlement is not attainable, the carrier shall promptly notify the IDRE within the period granted by the IDRE for negotiation.5. If the IDRE issues a determination in favor of the provider, the carrier shall pay the provider any additional amount owed within 30 days after the date of the determination.6. A carrier shall designate, and identify to the Superintendent, someone knowledgeable about the IDR process who shall be responsible for oversight of the carrier's compliance with the process. The carrier shall make at least one staff member available full time during normal business hours. The carrier shall respond to all inquiries from the Superintendent relating to the IDR process within five business days.7. A self-insured employer or the administrator of a self-insured health benefit plan may elect to be treated as a carrier under this rule by filing a notice in a form and manner prescribed by the Superintendent as provided in this subsection. The plan's rights and responsibilities as a carrier apply to all services provided to enrollees after the notice of participation is received by the Superintendent, unless the plan requests a different effective date. In order for the plan's participating status to remain in effect without interruption, a renewal notice must be received before the expiration of the plan year. The initial and renewal notices must include the following: A. the identity and contact information of the self-insured employer and the plan administrator;B. an agreement to submit to the jurisdiction of the Superintendent and to be bound by the requirements of this rule, the applicable provisions of the Maine Insurance Code, and any order or decision made by an IDRE pursuant to this rule; andC. evidence that the plan documents have been amended to reflect the applicability of the IDR process to the plan's enrollees.02-031 C.M.R. ch. 365, § 6