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27-21A-7
Section 27-21A-7 Evidence of coverage and charges for health care services. (a)(1) Every enrollee
residing in this state is entitled to an evidence of coverage. If the enrollee obtains such
coverage through an insurance policy or a contract issued by a health care service plan, the
insurer or the health care service plan shall issue the evidence of coverage. Otherwise, the
health maintenance organization shall issue the evidence of coverage. (2) No evidence of coverage,
or amendment thereto, shall be issued or delivered to any person in this state until a copy
of the basic form of the evidence of coverage, or amendment thereto, has been filed with the
commissioner and the State Health Officer, and approved by the commissioner. (3) An evidence
of coverage shall contain: a. No provisions or statements which encourage misrepresentation,
or which are untrue, misleading, or deceptive as defined in subsection (a) of Section 27-21A-13;
and b. A clear and concise statement, if a contract, or a...
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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...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/27-21A-1.htm - 3K - Match Info - Similar pages
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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27-1-17
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-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)...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/27-21A-17.htm - 3K - Match Info - Similar pages
27-21A-13
Section 27-21A-13 Prohibited practices. (a) No health maintenance organization, or representative
thereof, may cause or knowingly permit the use of advertising which is untrue or misleading,
solicitation which is untrue or misleading, or any form or evidence of coverage which is deceptive.
For purposes of this chapter: (1) A statement or item of information shall be deemed to be
untrue if it does not conform to fact in any respect which is or may be significant to an
enrollee of, or person considering enrollment with a health maintenance organization; (2)
A statement or item of information shall be deemed to be misleading, whether or not it may
be literally untrue, if, in the total context in which such statement is made or such item
of information is communicated, such statement or item of information may be reasonably understood
by a reasonable person, not possessing special knowledge regarding health care coverage, as
indicating any benefit or advantage or the absence of any...
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27-1-19
Section 27-1-19 Reimbursement of health care providers. (a) The insured, or health or dental
plan beneficiary may assign reimbursement for health or dental care services directly to the
provider of services. Health benefits include medical, pharmacy, podiatric, chiropractic,
optometric, durable medical equipment, and home care services. The company or agency, when
authorized by the insured, or health or dental plan beneficiary, shall pay directly to the
health care provider the amount of the claim, under the same criteria and payment schedule
that would have been reimbursed directly to the contract provider, and any applicable interest.
This amount only applies to assigned claims. Any company or agency making a payment to the
insured, or health or dental plan beneficiary, after the rights of reimbursement have been
assigned to the provider of services, shall be liable to the provider for the payment. If
the company or agency fails to reimburse the provider in accordance with the terms...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/27-1-19.htm - 2K - Match Info - Similar pages
27-12A-1
Section 27-12A-1 Definitions. As used in this chapter, the following terms shall have the following
meanings: (1) COMMISSIONER. The Alabama Commissioner of Insurance or his or her designee.
(2) DEPARTMENT. The Alabama Department of Insurance. (3) INSURANCE. As defined in Section
27-1-2, and specifically including any contract, arrangement, or agreement, in which one undertakes
to do any one of the following: a. Pay or indemnify another as to loss from certain contingencies
called risks. b. Pay or grant a specified amount or determinable benefit to another in connection
with ascertainable risk contingencies. c. Pay an annuity to another. d. Act as surety. For
the purposes of this chapter, insurance also includes any health benefit plan as defined in
Section 27-53-1. (4) INSURANCE PRODUCER or PRODUCER. As defined in Section 27-7-1. (5) INSURER.
A person entering into agreements, contracts of insurance, arrangements, or reinsurance, or
a health benefit plan, or a group health plan as...
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27-19-103
Section 27-19-103 Definitions. Unless the context requires otherwise, the definitions in this
section apply throughout this article. (1) APPLICANT. In the case of: a. An individual long-term
care insurance policy, the person who seeks to contract for benefits. b. A group long-term
care insurance policy, the proposed certificate holder. (2) CERTIFICATE. Any certificate issued
under a group long-term care insurance policy, which policy has been delivered or issued for
delivery in this state. (3) COMMISSIONER. The Alabama Commissioner of Insurance. (4) GROUP
LONG-TERM CARE INSURANCE. A long-term care insurance policy which is delivered or issued for
delivery in this state and issued to any of the following: a. One or more employers or labor
organizations, or to a trust or to the trustees of a fund established by one or more employers
or labor organizations, or a combination thereof, for employees or former employees or a combination
thereof, or for members or former members or a...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/27-19-103.htm - 9K - Match Info - Similar pages
27-55-3
Section 27-55-3 Prohibited practices; disclosure of information. (a) No insurer may: (1) Deny,
refuse to issue, renew, or reissue, cancel, or otherwise terminate, restrict, or exclude coverage
on an insurance policy or health benefit plan on the basis of an applicant's or insured's
abuse status, or on the basis of any association, relationship, or assistance to a subject
of abuse. (2) Exclude or limit coverage for a loss, deny benefits, or deny a claim on the
basis of the insured's abuse status, or on the basis of any association, relationship, or
assistance to a subject of abuse, except as otherwise permitted or required by the laws of
this state relating to acts of abuse committed by a life insurance beneficiary. Notwithstanding
anything to the contrary in this section, a liability insurer may include policy provisions
providing that a payment required by this subsection may be denied or, if paid, recovered
by the insurer from the insured, if the claim arose out of an act of abuse by...
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