11 NCAC 12 .1505             MANAGED CARE FORMS

(a)  As used in this Rule, "managed care plan" includes a health maintenance organization or a preferred provider organization.

(b)  The following managed care forms may be used by managed care plans, but shall not be a part of the standard claim form:

(1)           An "out‑of‑network" justification form shall be used by patients filing claims with their managed care plans when they have to justify the reasons they sought out‑of‑network health care services. This form shall be standardized, and the managed care plan industry shall develop and file this form with the Commissioner.

(2)           A "patient encounter form and electronic format" shall be used by managed care plans to record and report encounter information. This form shall provide information similar to the CMS Form 1450 (UB-04) and CMS Form 1500 and shall include information on patient identification, dates of services provided, types of services provided, and identities of health care providers. This form and electronic formats shall be standardized, and the managed care plan industry shall develop and file these with the Commissioner.

History Note:        Authority G.S. 58‑2‑40; 58‑3‑171;

Eff. October 1, 1994;

Readopted Eff. May 1, 2020.