33-20E-10. Dismissal of arbitration requests.

The Commissioner shall dismiss certain requests for arbitration if the disputed claim is:#

1. (1)

   Related to a healthcare plan that is not regulated by the state;#

2. (2)

   The basis for an action pending in state or federal court at the time of the request for arbitration;#

3. (3)

   Subject to a binding claims resolution process entered into prior to July 1, 2021;#

4. (4)

   Made against a healthcare plan subject to the exclusive jurisdiction of the Employee Retirement Income Security Act of 1974, 29 U.S.C. Sec. 1001, et seq.; or#

5. (5)

   In accord with other circumstances as may be determined by department rule.#

The Commissioner may dismiss certain requests for arbitration in the following circumstances:#

1. (1)

   The provider or facility has engaged in a pattern or practice of any of the following:#

   1. (A)

      Failing to respond to the department’s requests for data under Code Section 33-20E-11.1;#

   2. (B)

      Failing to respond to the department’s other inquires after filing requests for arbitration; or#

   3. (C)

      Failing to pay resolution organizations as required under Code Section 33-20E-16;#

2. (2)

   The provider or facility failed to file its request for arbitration within 60 days of receipt of payment for the claim and concurrently provide the insurer with a copy of such request; or#

3. (3)

   The provider or facility failed to explain in detail the reasons arbitration is needed. Such explanation shall include a representation as to whether the insurer’s payment was in accord with the relevant provisions of Code Sections 33-20E-4 or 33-20E-5 if the party requesting arbitration is an out-of-network provider, and Code Section 33-20E-4 if the requesting party is out-of-network facility. If such payment was in such accord, the explanation shall provide in detail the complexity and circumstances of the services provided which necessitate additional payment.#