SECTION 365:10-5-9. Disclosure of reasonable charge determination

(a)   Any contract or certificate of insurance issued by an insurance company, not-for-profit hospital service and medical indemnity plan, health insurance service organization or preferred provider organization which bases its payment for health care services, procedures, or supplies on a determination of average area charges for health care services, procedures, or supplies shall disclose that information to the contract purchaser and certificate holder at the time that the policy or certificate is delivered.

(b)   Average area charge means any determination of a charge for health care services, procedures, or supplies on a basis other than the billed rate or contracted rate of the health care provider. For example, average area charge includes, but is not limited to, the terms customary and reasonable, usually and customary, usual, customary, and reasonable, or other similar terms.

(c)   The disclosure shall be located on the first page or in a separate document affixed to the front page of the contract or certificate. The disclosure shall:

(1)   Be appropriately captioned and printed in font size at least two (2) points larger than the other text of the policy.

(2)   Reference the applicable section of the contract or certificate that specifies how average area charges are determined and provide an example of how this determination will affect the payment for services, procedures, or supplies of a health care provider. This example shall provide an explanation of the liability for charges of the insured that exceed the average area charge.

(3)   Advise the insured of the provisions of 36 O.S. § 6571 and provide a point of contact for health care providers to request the information used to determine the average area charge.

(4)   Include language advising the insured that noncompliance with 36 O.S. § 6571 should be reported to the Oklahoma Insurance Department.

[Source: Added at 27 Ok Reg 1531, eff 7-14-10]