§ 27-18-61 - Prompt processing of claims.
SECTION 27-18-61
§ 27-18-61 Prompt processing of claims.– (a) A health care entity or health plan operating in the state shall pay allcomplete claims for covered health care services submitted to the health careentity or health plan by a health care provider or by a policyholder withinforty (40) calendar days following the date of receipt of a complete writtenclaim or within thirty (30) calendar days following the date of receipt of acomplete electronic claim. Each health plan shall establish a written standarddefining what constitutes a complete claim and shall distribute this standardto all participating providers.
(b) If the health care entity or health plan denies or pendsa claim, the health care entity or health plan shall have thirty (30) calendardays from receipt of the claim to notify in writing the health care provider orpolicyholder of any and all reasons for denying or pending the claim and what,if any, additional information is required to process the claim. No health careentity or health plan may limit the time period in which additional informationmay be submitted to complete a claim.
(c) Any claim that is resubmitted by a health care provideror policyholder shall be treated by the health care entity or health planpursuant to the provisions of subsection (a) of this section.
(d) A health care entity or health plan which fails toreimburse the health care provider or policyholder after receipt by the healthcare entity or health plan of a complete claim within the required timeframesshall pay to the health care provider or the policyholder who submitted theclaim, in addition to any reimbursement for health care services provided,interest which shall accrue at the rate of twelve percent (12%) per annumcommencing on the thirty-first (31st) day after receipt of a completeelectronic claim or on the forty-first (41st) day after receipt of a completewritten claim, and ending on the date the payment is issued to the health careprovider or the policyholder.
(e) Exceptions to the requirements of this section are asfollows:
(1) No health care entity or health plan operating in thestate shall be in violation of this section for a claim submitted by a healthcare provider or policyholder if:
(i) Failure to comply is caused by a directive from a courtor federal or state agency;
(ii) The health care entity or health plan is in liquidationor rehabilitation or is operating in compliance with a court-ordered plan ofrehabilitation; or
(iii) The health care entity or health plan's compliance isrendered impossible due to matters beyond its control that are not caused by it.
(2) No health care entity or health plan operating in thestate shall be in violation of this section for any claim: (i) initiallysubmitted more than ninety (90) days after the service is rendered, or (ii)resubmitted more than ninety (90) days after the date the health care providerreceived the notice provided for in subsection (b) of this section; provided,this exception shall not apply in the event compliance is rendered impossibledue to matters beyond the control of the health care provider and were notcaused by the health care provider.
(3) No health care entity or health plan operating in thestate shall be in violation of this section while the claim is pending due to afraud investigation by a state or federal agency.
(4) No health care entity or health plan operating in thestate shall be obligated under this section to pay interest to any health careprovider or policyholder for any claim if the director of business regulationfinds that the entity or plan is in substantial compliance with this section. Ahealth care entity or health plan seeking such a finding from the directorshall submit any documentation that the director shall require. A health careentity or health plan which is found to be in substantial compliance with thissection shall thereafter submit any documentation that the director may requireon an annual basis for the director to assess ongoing compliance with thissection.
(5) A health care entity or health plan may petition thedirector for a waiver of the provision of this section for a period not toexceed ninety (90) days in the event the health care entity or health plan isconverting or substantially modifying its claims processing systems.
(f) For purposes of this section, the following definitionsapply:
(1) "Claim" means: (i) a bill or invoice for coveredservices; (ii) a line item of service; or (iii) all services for one patient orsubscriber within a bill or invoice.
(2) "Date of receipt" means the date the health care entityor health plan receives the claim whether via electronic submission or as apaper claim.
(3) "Health care entity" means a licensed insurance companyor nonprofit hospital or medical or dental service corporation or plan orhealth maintenance organization, or a contractor as described in §23-17.13-2(2), which operates a health plan.
(4) "Health care provider" means an individual clinician,either in practice independently or in a group, who provides health careservices, and otherwise referred to as a non-institutional provider.
(5) "Health care services" include, but are not limited to,medical, mental health, substance abuse, dental and any other services coveredunder the terms of the specific health plan.
(6) "Health plan" means a plan operated by a health careentity that provides for the delivery of health care services to personsenrolled in those plans through:
(i) Arrangements with selected providers to furnish healthcare services; and/or
(ii) Financial incentive for persons enrolled in the plan touse the participating providers and procedures provided for by the health plan.
(7) "Policyholder" means a person covered under a health planor a representative designated by that person.
(8) "Substantial compliance" means that the health careentity or health plan is processing and paying ninety-five percent (95%) ormore of all claims within the time frame provided for in subsections (a) and(b) of this section.
(g) Any provision in a contract between a health care entityor a health plan and a health care provider which is inconsistent with thissection shall be void and of no force and effect.