§1360.84. Prohibited and authorized practices

A. A direct practice shall not:

(1) Enter into a participating provider contract with any health insurance issuer or with any health insurance issuer's contractor or subcontractor to provide health care services through a direct agreement except as set forth in Subsection B of this Section.

(2) Submit a claim for payment to any health insurance issuer or any health insurance issuer's contractor or subcontractor for health care services provided to direct patients as covered by their agreement.

(3) With respect to services provided through a direct agreement, be identified by a health insurance issuer or any health insurance issuer's contractor or subcontractor as a participant in the health insurance issuer's or any health insurance issuer's contractor or subcontractor network for purposes of determining network adequacy or being available for selection by an enrollee under a health insurance issuer's benefit plan.

(4) Pay for health care services covered by a direct agreement rendered to direct patients by providers other than the providers in the direct practice or their employees, except as described in Subsection B of this Section.

B. A direct practice and provider may:

(1) Enter into a participating provider contract with a health insurance issuer for purposes other than payment of claims for services provided to direct patients through a direct agreement. Such physicians shall be subject to all other provisions of the participating provider contract applicable to participating providers, including but not limited to the right to:

(a) Make referrals to other participating providers.

(b) Admit the carrier's members to participating hospitals and other health care facilities.

(c) Prescribe prescription drugs.

(d) Implement other customary provisions of the contract not dealing with reimbursement of services.

(2) Pay for charges associated with:

(a) The provision of routine lab and imaging services.

(b) Dispensing, at no additional cost to the direct patient, of prescription drugs prescribed by the direct provider in accordance with state law and regulations promulgated by the board.

(3) Charge an additional fee to direct patients for supplies, medications, and specific vaccines provided to direct patients that are specifically excluded under the agreement, provided the direct practice notifies the direct patient of the additional charge, prior to their administration or delivery.

Acts 2014, No. 867, §1.