Sec. 10.18.07.07. Payment Procedures

A. A recipient, recipient’s representative, health care provider, insurer, employer, or health plan administrator, as applicable:

(1) May request payment costs allowed under this chapter on behalf of the recipient according to procedures established by the Department;

(2) Shall submit a payment request that is:

(a) An invoice for the recipient’s health or prescription drug plan insurance premium, copays, coinsurance, and deductibles for core medical services issued by an insurer, an employer, a health plan administrator, prescription drug plan administrator, or a health care provider; and

(b) Submitted timely to allow for payment in accordance with §§A(3) and B(4) of this regulation; and

(3) Shall make the initial request for the payment of costs within the time frames established by the health or prescription drug insurance policy.

B. The Department:

(1) Shall process a payment request as required by this chapter;

(2) Shall inform a recipient or the recipient’s representative if an invoice is not paid;

(3) Shall make payments in accordance with any applicable policies and procedures for the administration of federal funds issued pursuant to the Ryan White CARE Act Amendments of 1996, P. L. 104-146, and any subsequent modifications to the Act; and

(4) Shall make subsequent payments:

(a) As permitted under a health or prescription drug plan; or

(b) Upon agreement between the Department and the:

(i) Insurer;

(ii) Employer;

(iii) Health plan administrator;

(iv) Prescription drug plan administrator; or

(iv) Health care provider.