§ 4324. Disclosure of information. The requirements of this section\nshall apply to all comprehensive, expense-reimbursed contracts; managed\ncare products; or any other contract or product for which the\nsuperintendent deems such disclosure appropriate.\n (a) Each health service, hospital service, or medical expense\nindemnity corporation subject to this article shall supply each\nsubscriber, and upon request each prospective subscriber prior to\nenrollment, written disclosure information, which may be incorporated\ninto the subscriber contract or certificate, containing at least the\ninformation set forth below. In the event of any inconsistency between\nany separate written disclosure statement and the subscriber contract or\ncertificate, the terms of the subscriber contract or certificate shall\nbe controlling. The information to be disclosed shall include at least\nthe following:\n (1) a description of coverage provisions; health care benefits;\nbenefit maximums, including benefit limitations; and exclusions of\ncoverage, including the definition of medical necessity used in\ndetermining whether benefits will be covered;\n (2) a description of all prior authorization or other requirements for\ntreatments and services;\n (3) a description of utilization review policies and procedures, used\nby the corporation, including:\n (A) the circumstances under which utilization review will be\nundertaken;\n (B) the toll-free telephone number of the utilization review agent;\n (C) the time frames under which utilization review decisions must be\nmade for prospective, retrospective and concurrent decisions;\n (D) the right to reconsideration;\n (E) the right to an appeal, including the expedited and standard\nappeals processes and the time frames for such appeals;\n (F) the right to designate a representative;\n (G) a notice that all denials of claims will be made by qualified\nclinical personnel and that all notices of denials will include\ninformation about the basis of the decision;\n (H) a notice of the right to an external appeal together with a\ndescription, jointly promulgated by the superintendent and the\ncommissioner of health as required pursuant to subsection (e) of section\nfour thousand nine hundred fourteen of this chapter, of the external\nappeal process established pursuant to title two of article forty-nine\nof this chapter and the time frames for such appeals; and\n (I) further appeal rights, if any;\n (4) a description prepared annually of the types of methodologies the\ncorporation uses to reimburse providers, specifying the type of\nmethodology that is used to reimburse particular types of providers or\nreimburse for the provision of particular types of services; provided,\nhowever, that nothing in this paragraph should be construed to require\ndisclosure of individual contracts or the specific details of any\nfinancial arrangement between a corporation and a health care provider;\n (5) an explanation of a subscriber's financial responsibility for\npayment of premiums, coinsurance, co-payments, deductibles and any other\ncharges, annual limits on a subscriber's financial responsibility, caps\non payments for covered services and financial responsibility for\nnon-covered health care procedures, treatments or services;\n (6) an explanation, where applicable, of a subscriber's financial\nresponsibility for payment when services are provided by a health care\nprovider who is not part of the corporation's network of providers or by\nany provider without required authorization;\n (7) a description of the grievance procedures to be used to resolve\ndisputes between the corporation and a subscriber, including: the right\nto file a grievance regarding any dispute between the corporation and a\nsubscriber; the right to file a grievance orally when the dispute is\nabout referrals or covered benefits; the toll-free telephone number\nwhich subscribers may use to file an oral grievance; the timeframes and\nci
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