376.423. Health insurance, claims for chiropractic services denial, qualified chiropractor to review, qualifications--investigation by department, when.
Health insurance, claims for chiropractic services denial,qualified chiropractor to review, qualifications--investigationby department, when.
376.423. 1. Beginning January 1, 1993, any consultant retained by anyinsurance company, health services corporation and any self-insured grouparrangement 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 ofMissouri, and, if the claim is made from a metropolitan statistical area inMissouri as that term is defined by the United States Bureau of the Census,then he shall be practicing as a chiropractor in any such metropolitanstatistical area in Missouri; or be licensed and practicing as a chiropractorin the state in which the claim is reviewed;
(2) Obtain a certificate from the board of chiropractic examiners, whichshall indicate that the licensee has complied with the provisions of thissection and has met the minimum standards contained in this section. Theapplication for a certificate shall be on a form provided by the board;
(3) Provide to the board of chiropractic examiners, in addition to theother information required to be provided on the application, certificationthat the licensee has either:
(a) Successfully completed at least one hundred hours of postgraduatetraining in insurance claims consulting, which training was presented by acollege of chiropractic having status with the council on chiropracticeducation; or
(b) Successfully completed at least one hundred hours training ininsurance claims consulting in the course of study approved by the board ofchiropractic examiners; and
(4) Have received at least one-half of his earned income from theclinical practice of chiropractic. The term "clinical practice ofchiropractic" shall not include the review of claims regulated by this sectionnor any of the paperwork which is or becomes part of the review nor any of theincome from examining a person whose claim is being reviewed.
2. The compensation of such consultant shall not be based on apercentage of the amount by which a claim is reduced for payment.
3. Upon receipt of a complaint from the insured or the chiropractoralleging an adverse chiropractic review determination, the director of thedepartment of insurance, financial institutions and professional registrationshall investigate to determine whether the insurance company or healthservices corporation has engaged in an unfair claims settlement practice underthe provisions of subdivision (10) of section 375.936, RSMo, or a violation ofthis section. The department of insurance, financial institutions andprofessional registration shall promulgate rules to enforce the provisions ofthis subsection.
4. Any licensee who shall advertise or announce to the public in anycommunication or solicitation that he engages in or provides insurance claimsconsulting in any aspect without having first complied with this section shallbe deemed to have engaged in false, misleading or deceptive advertising.
5. It shall be unlawful for any person who is licensed under theprovisions of chapter 331, RSMo, to accept employment as a consultant toreview health care claims for services rendered by any chiropractor unless hemeets the qualifications and conditions of subsection 1 of this section. Theprovisions of this subsection shall be enforced by the board of chiropracticexaminers, which administers the provisions of chapter 331, RSMo. Violationsof this section shall constitute grounds for disciplinary action pursuant tosection 331.060, RSMo.
6. The board of chiropractic examiners may by rule establish and enforcethe conditions under which it will issue certificates of compliance.
7. The board of chiropractic examiners is authorized, pursuant tosection 331.070, RSMo, to set fees to cover the cost and expense ofadministering this section.
(L. 1990 H.B. 1739 § 13, A.L. 1992 S.B. 698, A.L. 1993 S.B. 52, A.L. 1997 H.B. 335)