This regulation is adopted by the Commissioner pursuant to 18 Del.C. §§311, 2304(16) and 2312. It is promulgated in accordance with 29 Del.C. Ch. 101.
2.1 For the purpose of this regulation, the following definitions shall apply:
“Assistant at Surgery” means a physician, nurse practitioner, clinical nurse specialist, or physician assistant who is licensed and actively assists the physician in charge of a case in performing a surgical procedure.
“Fee schedule” means the monetary allowance payable to a healthcare provider for services rendered as provided for by agreement between the health care provider and the health insurer.
“Health Care Provider” means any entity or individual licensed, certified or otherwise permitted by law to provide health care in the ordinary course of business, practice or profession.
“Health insurer” means health insurance companies, health maintenance organizations, health service corporations and any other entity providing a plan of health insurance or benefits subject to state insurance regulations.
“Policyholder or Certificate Holder” means a person covered under such policy or a representative designated by such person and entitled to services provided in the policy.
5.0 Guidelines for payment for the services of assistants at surgery
5.2.3 whether the surgical procedure in question is eligible for assistant at surgery services.
In addition to the imposition of penalties in accordance with 18 Del.C. §2312(b), any health insurer that fails to adhere to the standards contained in this regulation may be required by order of the Commissioner to pay to the health care provider or claimant, in full settlement of the claim or bill for health care services, the amount of the claim or bill plus interest at the maximum rate allowable to lenders under 6 Del.C. §2301(a). Such interest shall be computed from the date the claim or bill for services first became due.
8.0 Causes of Action and Defenses
This regulation shall not create a cause of action for any person or entity, other than the Delaware Insurance Commissioner, against a health insurer or its representative based upon a violation of 18 Del.C. §2304(16). In the same manner, nothing in this regulation shall establish a defense for any party to any cause of action based upon a violation of 18 Del.C. §2304(16).