H. B.4776
(By Delegates Douglas, Kuhn, Flanigan, Angotti,
Manchin, Azinger and Stalnaker)
(Originating in the House Committee on Government Organization)
[February 28, 2000]
A BILL to amend and reenact sections one, two, three and four,
article fifteen-b, chapter thirty-three of the code of West
Virginia, one thousand nine hundred thirty-one, as amended;
and to further amend said article by adding thereto two new
sections, designated sections five and six, all relating to
uniform health care administration, the transfer of
responsibilities to develop standard forms and procedures
regarding health care claims and all other requirements and
procedures under this article from the authority of the
insurance commissioner to the West Virginia health care
authority; and establishing penalties for violation of the
uniform health care administration act.
Be it enacted by the Legislature of West Virginia:
That sections one, two, three, four, article fifteen-b,
chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended and reenacted; and
to further amend said article by adding thereto two new sections,
designated sections five and six, all to read as follows:
ARTICLE 15B. UNIFORM HEALTH CARE ADMINISTRATION ACT.
§33-15B-1. Legislative findings; purpose.
The Legislature hereby finds that there is a need to provide
guidelines regarding uniform health care administration in order to
best serve consumers, health care providers and insurers and to
organize and streamline the claims process. The purpose of this
article is to require the transfer of the authority of the
insurance commissioner to develop standard forms and procedures
regarding health care claims and to require that all insurers,
third party providers, and health care providers implement and use
such standards in a uniform manner to the West Virginia health care
authority. The West Virginia health care authority is responsible
for coordinating and overseeing the health data collection in West
Virginia and coordinating database development, analysis and
reporting to facilitate cost management, utilization review, and
quality assurance efforts by state payors and regulatory agencies,
insurers, consumers, providers, and other interested parties. The
Legislature finds that the West Virginia health care authority is
the appropriate agency to oversee the development of standard forms
and procedures regarding health care claims. Thus, the Legislature
hereby transfers the responsibilities to develop standard forms and procedures regarding health care claims and all other requirements
and procedures under this article to the West Virginia health care
authority.
§33-15B-2. Scope of article.
The provisions of this article apply to all health care
providers in the state, including but not limited to, all insurers
writing or issuing accident and sickness policies; covered by
article fifteen of this chapter; hospital service corporations;
health service corporations; medical service corporations; and
dental service corporations; organized in accordance with the
provisions of article one, chapter thirty-one and chapter thirty-
three of this code; all third party providers; all state agencies
and departments, including, but not limited to, the public
employees insurance agency, workers' compensation insurance, and
providers of services under medicare and medicaid.
§33-15B-3. Health care authority to promulgate rules; use of
standardized forms and classifications; advisory group.
(a) The insurance commissioner West Virginia health care
authority shall promulgate legislative rules in accordance with the
provisions of chapter twenty-nine-a of this code regarding the
implementation and use of uniform health care administrative forms.
Such rules shall be developed no later than the first day of
December, one thousand nine hundred ninety-two, and shall
establish, where practicable, the acceptance and use throughout the health care system of standard administrative forms, terms or
procedures, including, but not limited to, the following:
(1) The standard health care financing administration fifteen
hundred (HCFA 1500) health insurance claim form, as amended, or
other similar forms, and terms, and definitions to be used
therewith which are consistent with health care and insurance
industry standards.
(2) International classification of disease, ninth clinical
modifications (ICD-9-CM) and common procedural terminology (CPT)
codes, as amended, or another other similar standard code forms,
terms, and definitions to be used which are consistent with health
care and insurance industry standards.
(3)National uniform billing data element specifications (UB-
92), as amended, and as supplemented by the West Virginia uniform
billing committee, or other similar forms, terms, and definitions
to be used which are consistent with health care and insurance
industry standards.
(34) Consideration of current practices involving
reimbursement of claims and explanation of benefits, and the
implementation of standards and guidelines regarding explanation of
benefits, including, but not limited to, consideration of line item
explanations of payments or denial of payments.
(b) The legislative rules required herein shall be developed
by the insurance commissioner West Virginia health care authority with the advice of a thirteen-member panel an advisory group to be
appointed by the commissioner board of the West Virginia health
care authority. Such panel advisory group shall consist of the
insurance commissioner; one allopath and one osteopath who shall be
recommended by the West Virginia state medical association; a
representative of the hospital industry who shall be recommended by
the West Virginia hospital association; one dentist recommended by
the West Virginia dental association and one pharmacist recommended
by the West Virginia pharmacists association; two members
representing commercial health insurers who shall be recommended by
the association representing accident and sickness insurance; a
representative of third party administrators; a representative of
the public employees insurance agency; a representative from the
workers' compensation commission; and two members representing
consumers representatives of consumers, providers, payors, and
regulatory agencies, including representatives from the following:
the office of the insurance commissioner; the West Virginia health
care authority; West Virginia dental association; West Virginia
pharmacists association; the West Virginia hospital association;
commercial health insurers; third party administrators; public
employees insurance agency; workers compensation commission; and
consumers. The insurance commissioner West Virginia health care
authority shall make such appointments thirty days form such
advisory group after the effective date of this section.
(c) The insurance commissioner West Virginia health care
authority and the advisory panel group shall review the legislative
rules effected pursuant to this section as necessary on at least an
annual basis and update the same in a timely manner in order to
conform to current legislation and health care administrative and
insurance industry standards and trends.
§33-15B-4. Compliance period; reservation of right to additional
information.
(a) All health care providers, insurers, third party providers
and state agencies or departments shall have one year from the date
the insurance commissioner West Virginia health care authority
establishes the legislative rules required by section three herein
this article to comply with the requirements of the same.
(b) This section shall not limit the right of any insurer,
third party provider, state agency or department to require
additional information on any claim.
§33-15B-5. Penalties for violation.
Any person, partnership, corporation, limited liability
company, professional corporation, health care provider or other
entity violating any provision of this article shall be guilty of
a misdemeanor and, upon conviction shall be punished by a fine of
not more than one thousand dollars. Each day of continuing
violation after conviction shall be considered a separate offense.
The West Virginia health care authority is empowered to withhold rate approval or a certificate of need for any health care provider
violating any provision of this article.
§33-15B-6. Citation of article.
This article may be known as the "Uniform Health Care
Administration Act."
Strike-throughs indicate language that would be stricken from the
present law, and underscoring indicates new language that would be
added.
Sections 33-15B-5 and 6 are new, therefore, underlining and
strike-throughs have been omitted.