<html> <head> <title>Rule 20:06:55:0A Model Choice of Health Care Professional Notice Language.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:55:0A"> <META NAME="Description" Content="Administrative Rules 20:06:55:0A Model Choice of Health Care Professional Notice Language."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; text-align:justify; font-size:12.0pt; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>MODEL CHOICE OF HEALTH CARE PROFESSIONAL NOTICE LANGUAGE</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Chapter 20:06:55</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>APPENDIX A</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>SEE&nbsp; &#167;&nbsp;20:06:55:12</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Source: 37 SDR 111, effective December 7, 2010; 39 SDR 203, effective June 10, 2013.</span></font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Appendix A - Model Choice of Health Care Professional Notice Language</span></font></b></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&#9679;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; For health carries that require or allow for the designation of primary care health care professionals, beneficiaries or enrollees, insert:</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>[Name of health insurance issuer] generally [requires/allows] the designation of a primary care health care professional. You have the right to designate any primary care health care professional who participates in our network and who is available to accept you or your family members.</span></font></b> [If the health insurance issuer designates a primary care health care professional automatically, insert: <b><span style='font-weight:bold'>Until you make this designation, [name of health insurance issuer] designates one for you.] For information on how to select a primary care health care professional, and for a list of participating primary care health care professionals, contact the [health insurance issuer] at [insert contact information].</span></b></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&#9679;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; For health insurance issuers that require or allow for the designation of a primary care health care professional for a child, add:</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; For children, you may designate a pediatrician as the primary care health care professional.</span></font></b></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&#9679;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; For health insurance issuers that provide coverage for obstetric or gynecological care and require the designation by a participant, beneficiary or enrollee of a primary care health care professional, add:</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; You do not need prior authorization from [name of health insurance issuer] or from any other person, including a primary care health care professional, in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the [health insurance issuer] at [insert contact information].</span></font></b></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;</span></font></p> </div> </body> </html>