TITLE 27
Insurance
CHAPTER 27-20
Nonprofit Medical Service Corporations
SECTION 27-20-47
§ 27-20-47 Prompt processing of claims.
(a) A health care entity or health plan operating in the state shall pay all
complete claims for covered health care services submitted to the health care
entity or health plan by a health care provider or by a policyholder within
forty (40) calendar days following the date of receipt of a complete written
claim or within thirty (30) calendar days following the date of receipt of a
complete electronic claim. Each health plan shall establish a written standard
defining what constitutes a complete claim and shall distribute the standard to
all participating providers.
(b) If the health care entity or health plan denies or pends
a claim, the health care entity or health plan shall have thirty (30) calendar
days from receipt of the claim to notify in writing the health care provider or
policyholder 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 care
entity or health plan may limit the time period in which additional information
may be submitted to complete a claim.
(c) Any claim that is resubmitted by a health care provider
or policyholder shall be treated by the health care entity or health plan
pursuant to the provisions of subsection (a) of this section.
(d) A health care entity or health plan which fails to
reimburse the health care provider or policyholder after receipt by the health
care entity or health plan of a complete claim within the required timeframes
shall pay to the health care provider or the policyholder who submitted the
claim, in addition to any reimbursement for health care services provided,
interest which shall accrue at the rate of twelve percent (12%) per annum
commencing on the thirty-first (31st) day after receipt of a complete
electronic claim or on the forty-first (41st) day after receipt of a complete
written claim, and ending on the date the payment is issued to the health care
provider or the policyholder.
(e) Exceptions to the requirements of this section are as
follows:
(1) No health care entity or health plan operating in the
state shall be in violation of this section for a claim submitted by a health
care provider or policyholder if:
(i) Failure to comply is caused by a directive from a court
or federal or state agency;
(ii) The health care entity or health plan is in liquidation
or rehabilitation or is operating in compliance with a court-ordered plan of
rehabilitation; or
(iii) The health care entity or health plan's compliance is
rendered impossible due to matters beyond its control that are not caused by it.
(2) No health care entity or health plan operating in the
state shall be in violation of this section for any claim: (i) initially
submitted more than ninety (90) days after the service is rendered, or (ii)
resubmitted more than ninety (90) days after the date the health care provider
received the notice provided for in § 27-18-61(b); provided, this
exception shall not apply in the event compliance is rendered impossible due to
matters beyond the control of the health care provider and were not caused by
the health care provider.
(3) No health care entity or health plan operating in the
state shall be in violation of this section while the claim is pending due to a
fraud investigation by a state or federal agency.
(4) No health care entity or health plan operating in the
state shall be obligated under this section to pay interest to any health care
provider or policyholder for any claim if the director of the department of
business regulation finds that the entity or plan is in substantial compliance
with this section. A health care entity or health plan seeking such a finding
from the director shall submit any documentation that the director shall
require. A health care entity or health plan which is found to be in
substantial compliance with this section shall after this submit any
documentation that the director may require on an annual basis for the director
to assess ongoing compliance with this section.
(5) A health care entity or health plan may petition the
director for a waiver of the provision of this section for a period not to
exceed ninety (90) days in the event the health care entity or health plan is
converting or substantially modifying its claims processing systems.
(f) For purposes of this section, the following definitions
apply:
(1) "Claim" means: (i) a bill or invoice for covered
services; (ii) a line item of service; or (iii) all services for one patient or
subscriber within a bill or invoice.
(2) "Date of receipt" means the date the health care entity
or health plan receives the claim whether via electronic submission or has a
paper claim.
(3) "Health care entity" means a licensed insurance company
or nonprofit hospital or medical or dental service corporation or plan or
health maintenance organization, or a contractor as described in §
23-17.13-2(2), that operates a health plan.
(4) "Health care provider" means an individual clinician,
either in practice independently or in a group, who provides health care
services, and 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 covered
under the terms of the specific health plan.
(6) "Health plan" means a plan operated by a health care
entity that provides for the delivery of health care services to persons
enrolled in the plan through:
(i) Arrangements with selected providers to furnish health
care services; and/or
(ii) Financial incentive for persons enrolled in the plan to
use the participating providers and procedures provided for by the health plan.
(7) "Policyholder" means a person covered under a health plan
or a representative designated by that person.
(8) "Substantial compliance" means that the health care
entity or health plan is processing and paying ninety-five percent (95%) or
more of all claims within the time frame provided for in § 27-18-61(a) and
(b).
(g) Any provision in a contract between a health care entity
or a health plan and a health care provider which is inconsistent with this
section shall be void and of no force and effect.
History of Section.
(P.L. 2001, ch. 119, § 3; P.L. 2001, ch. 380, § 3.)
