Effective 28 Aug 1997

376.423. Health insurance, claims for chiropractic services denial, qualified chiropractor to review, qualifications — investigation by department, when. — 1. Beginning January 1, 1993, any consultant retained by any insurance company, health services corporation and any self-insured group arrangement to the extent not preempted by federal law, to review claims, under any policy of accident and sickness insurance or membership contract, denied in whole or in part for services rendered by a chiropractor shall:

(1) Be licensed and practicing as a chiropractor in the state of Missouri, and, if the claim is made from a metropolitan statistical area in Missouri as that term is defined by the United States Bureau of the Census, then he shall be practicing as a chiropractor in any such metropolitan statistical area in Missouri; or be licensed and practicing as a chiropractor in the state in which the claim is reviewed;

(2) Obtain a certificate from the board of chiropractic examiners, which shall indicate that the licensee has complied with the provisions of this section and has met the minimum standards contained in this section. The application for a certificate shall be on a form provided by the board;

(3) Provide to the board of chiropractic examiners, in addition to the other information required to be provided on the application, certification that the licensee has either:

(a) Successfully completed at least one hundred hours of postgraduate training in insurance claims consulting, which training was presented by a college of chiropractic having status with the council on chiropractic education; or

(b) Successfully completed at least one hundred hours training in insurance claims consulting in the course of study approved by the board of chiropractic examiners; and

(4) Have received at least one-half of his earned income from the clinical practice of chiropractic. The term "clinical practice of chiropractic" shall not include the review of claims regulated by this section nor any of the paperwork which is or becomes part of the review nor any of the income from examining a person whose claim is being reviewed.

2. The compensation of such consultant shall not be based on a percentage of the amount by which a claim is reduced for payment.

3. Upon receipt of a complaint from the insured or the chiropractor alleging an adverse chiropractic review determination, the director of the department of commerce and insurance shall investigate to determine whether the insurance company or health services corporation has engaged in an unfair claims settlement practice under the provisions of subdivision (10) of section 375.936 or a violation of this section. The department of commerce and insurance shall promulgate rules to enforce the provisions of this subsection.

4. Any licensee who shall advertise or announce to the public in any communication or solicitation that he engages in or provides insurance claims consulting in any aspect without having first complied with this section shall be deemed to have engaged in false, misleading or deceptive advertising.

5. It shall be unlawful for any person who is licensed under the provisions of chapter 331 to accept employment as a consultant to review health care claims for services rendered by any chiropractor unless he meets the qualifications and conditions of subsection 1 of this section. The provisions of this subsection shall be enforced by the board of chiropractic examiners, which administers the provisions of chapter 331. Violations of this section shall constitute grounds for disciplinary action pursuant to section 331.060.

6. The board of chiropractic examiners may by rule establish and enforce the conditions under which it will issue certificates of compliance.

7. The board of chiropractic examiners is authorized, pursuant to section 331.070, to set fees to cover the cost and expense of administering this section.

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(L. 1990 H.B. 1739 § 13, A.L. 1992 S.B. 698, A.L. 1993 S.B. 52, A.L. 1997 H.B. 335)