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27-21A-17
Section 27-21A-17 Suspension or revocation of certificate of authority. (a) The commissioner
in consultation with and with the approval of the State Health Officer, where necessary, may
suspend or revoke any certificate of authority issued to a health maintenance organization
under this chapter if he finds that any of the following conditions exist: (1) The health
maintenance organization is operating significantly in contravention of its basic organizational
document or in a manner contrary to that described in any other information submitted under
Section 27-21A-2, unless amendments to such submissions have been filed with the commissioner
and the State Health Officer and approved by the commissioner; (2) The health maintenance
organization issues evidence of coverage or uses a schedule of charges for health care services
which do not comply with requirements of Section 27-21A-7; (3) The health maintenance
organization does not provide or arrange for basic health care services; (4)...
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27-21A-3
Section 27-21A-3 Issuance of certificate of authority. (a)(1) Upon receipt of an application
for issuance of a certificate of authority, the commissioner shall forthwith transmit copies
of such application and accompanying documents to the State Health Officer. (2) The State
Health Officer shall determine whether the applicant for a certificate of authority, with
respect to health care services to be furnished: a. Has demonstrated the willingness and potential
ability to assure that such health care services will be provided in a manner to assure both
availability and accessibility of adequate personnel and facilities and in a manner enhancing
availability, accessibility, and continuity of service; b. Has arrangements, established in
accordance with the regulations promulgated by the State Health Officer, for an on-going quality
assurance program concerning health care processes and outcomes; and c. Has a procedure, established
in accordance with regulations of the State Health...
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27-21A-2
Section 27-21A-2 Establishment of health maintenance organizations. (a) Notwithstanding
any law of this state to the contrary, any person may apply to the commissioner for and obtain
a certificate of authority to establish and operate a health maintenance organization in compliance
with this chapter. No person shall establish or operate a health maintenance organization
in this state without obtaining a certificate of authority under this chapter. A foreign corporation
may qualify under this chapter, subject to its registration to do business in this state as
a foreign corporation under the provisions of Sections 10-2A-220, et seq. (b) Health maintenance
organizations licensed as of May 29, 1986, shall be issued a certificate of authority in accordance
with Section 27-21A-29. (c) Each application for a certificate of authority shall be
verified by an officer or authorized representative of the applicant, shall be in a form prescribed
by the commissioner, and shall set forth or be...
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27-21A-20
Section 27-21A-20 Administrative procedures. (a) When the commissioner has cause to
believe that grounds for the denial of an application for a certificate of authority exist,
or that grounds for the suspension or revocation of a certificate of authority exist, he shall
notify the health maintenance organization and the State Health Officer in writing specifically
stating the grounds for denial, suspension, or revocation. If so requested in writing by the
health maintenance organization, the commissioner shall set a hearing on the matter within
30 days of the receipt of such request. (b) The State Health Officer, or his designated representative,
shall be in attendance at the hearing and shall participate in the proceedings. The recommendation
and findings of the State Health Officer with respect to matters relating to the quality of
health care services provided in connection with any decision regarding denial, suspension,
or revocation of a certificate of authority, shall be...
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27-44-5
Section 27-44-5 Definitions. As used in this chapter, the following terms shall have
the following meanings, respectively, unless the context clearly indicates otherwise: (1)
ACCOUNT. Either of the three accounts created under Section 27-44-6. (2) ASSOCIATION.
The Alabama Life and Disability Insurance Guaranty Association created under Section
27-44-6. (3) AUTHORIZED ASSESSMENT or the term AUTHORIZED when used in the context of assessments.
A resolution by the board of directors has been passed whereby an assessment will be called
immediately or in the future from member insurers for a specified amount. An assessment is
authorized when the resolution is passed. (4) BENEFIT PLAN. A specific employee, union, or
association of natural persons benefit plan. (5) CALLED ASSESSMENT or the term CALLED when
used in the context of assessments. A notice that has been issued by the association to member
insurers requiring that an authorized assessment be paid within the time frame set forth within...
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27-1-17
Section 27-1-17 Limitation periods for payment of claims; overdue claims; retroactive
denials, adjustments, etc.; penalties. (a) Each insurer, health service corporation, and health
benefit plan that issues or renews any policy of accident or health insurance providing benefits
for medical or hospital expenses for its insured persons shall pay for services rendered by
Alabama health care providers within 45 calendar days upon receipt of a clean written claim
or 30 calendar days upon receipt of a clean electronic claim. If the insurer, health service
corporation, or health benefit plan is denying or pending the claim, the insurer, health service
corporation, or health benefit plan shall, within 45 calendar days for a written claim and
30 calendar days for an electronic claim, notify the health care provider or certificate holder
of the reason for denying or pending the claim and what, if any, additional information is
required to process the claim. Any undisputed portion of the claim...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/27-1-17.htm - 17K - Match Info - Similar pages
27-21A-23
Section 27-21A-23 Statutory construction and relationship to other laws. (a) Except
as otherwise provided in this chapter, provisions of the insurance law and provisions of health
care service plan laws shall not be applicable to any health maintenance organization granted
a certificate of authority under this chapter. This provision shall not apply to an insurer
or health care service plan licensed and regulated pursuant to the insurance law or the health
care service plan laws of this state except with respect to its health maintenance organization
activities authorized and regulated pursuant to this chapter. (b) Solicitation of enrollees
by a health maintenance organization granted a certificate of authority shall not be construed
to violate any provision of law relating to solicitation or advertising by health professionals.
(c) Any health maintenance organization authorized under this chapter shall not be deemed
to be practicing medicine and shall be exempt from the provisions of...
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27-21A-22
Section 27-21A-22 Penalties and enforcement. (a) The commissioner may, in lieu of suspension
or revocation of a certificate of authority under Section 27-21A-17, levy an administrative
penalty in an amount not less than $500.00 nor more than $5,000.00, if reasonable notice in
writing is given of the intent to levy the penalty and the health maintenance organization
has a reasonable time within which to remedy the defect in its operations which gave rise
to the penalty citation. The commissioner may augment this penalty by an amount equal to the
sum that he calculates to be the damages suffered by enrollees or other members of the public.
All moneys collected under this section shall be deposited to the credit of the General
Fund. (b)(1) If the commissioner or the State Health Officer shall for any reason have cause
to believe that any violation of this chapter has occurred or is threatened, the commissioner
or State Health Officer may give notice to the health maintenance organization...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/27-21A-22.htm - 3K - Match Info - Similar pages
27-21A-29
Section 27-21A-29 Existing health maintenance organizations. (a) Notwithstanding any
other provision of this chapter, any health maintenance organization licensed by the State
Board of Health and in operation on May 29, 1986, shall be granted a certificate of authority
upon payment of the application fee prescribed in Section 27-21A-21 and compliance
with Section 27-21A-12. Nothing in this section shall prohibit any such health
maintenance organization from continuing to conduct business in this state until such certificate
of authority is issued. (b) Any health maintenance organization which was licensed in this
state prior to January 1, 1986, may continue to operate under existing noncontractual provider
arrangements (which have been approved by the State Health Officer) for three years. (c) After
issuance of a certificate of authority in accordance with subsection (a) of this section,
the commissioner may require submission by the health maintenance organization of any additional...
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27-21A-1
Section 27-21A-1 Definitions. As used in this chapter, the following terms shall have
the following meanings, respectively: (1) AGENT. A person who is appointed or employed by
a health maintenance organization and who engages in solicitation of membership in such organization.
This definition does not include a person enrolling members on behalf of an employer, union,
or other organization. (2) BASIC HEALTH CARE SERVICES. Emergency care, inpatient hospital
and physician care, and outpatient medical services. (3) COMMISSIONER. The Commissioner of
Insurance. (4) ENROLLEE. An individual who is enrolled in a health maintenance organization.
(5) EVIDENCE OF COVERAGE. Any certificate, agreement, or contract issued to an enrollee setting
out the coverage to which he is entitled. (6) HEALTH CARE SERVICES. Any services included
in the furnishing to any individual of medical or dental care, or hospitalization or incident
to the furnishing of such care or hospitalization, as well as the...
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