A. A carrier shall provide the information listed in §B of this regulation with the payment to the insured for health care services if:
(1) The carrier receives a claim for health care services provided by a physician who is a nonpreferred provider and who is not an on-call physician or a hospital-based physician; and
(2) The insured did not provide an assignment of benefits to the physician who provided the health care services.
B. The information required by §A of this regulation shall include:
(1) The specific claim covered by the payment;
(2) The amount paid for the claim;
(3) The amount that is the insuredís responsibility; and
(4) A statement instructing the insured to use the payment to pay the nonpreferred provider in the event the insured has not paid the nonpreferred provider in full for the health care services rendered by the nonpreferred provider.
C. If the payment for a claim is sent to the insured by the carrier with an explanation of benefits, the carrier shall include the information required to be provided under §§A and B of this regulation on the explanation of benefits or on a separate page included with the explanation of benefits.
D. If the payment for a claim is sent to the insured by the carrier separately from the explanation of benefits, the carrier shall include the information required under §§A and B of this regulation with the payment of claim.