31 Pa. Code § 154.18 - Prompt payment
(a) Licensed
insurers and managed care plans shall pay clean claims and the uncontested
portions of a contested claim under subsection (d) submitted by a health care
provider for services provided on or after January 1, 1999, within 45 days of
the licensed insurer's or managed care plan's receipt of the claim from the
health care provider. The prompt payment provision applies only to claims
submitted under health insurance policies, excluding areas such as automobile
and worker's compensation policies.
(b) For purposes of prompt payment, a claim
shall be deemed to have been "paid" upon one of the following:
(1) A check is mailed by the licensed insurer
or managed care plan to the health care provider.
(2) An electronic transfer of funds is made
from the licensed insurer or managed care plan to the health care
provider.
(c) Interest
due to a health care provider on a clean claim shall be calculated and paid by
the licensed insurer or managed care plan to the health care provider and shall
be added to the amount owed on the clean claim. The interest shall be paid
within 30 days of the payment of the claim. Interest owed of less than $2 on a
single claim does not have to be paid by the licensed insurer or managed care
plan. Interest can be paid on the same check as the claim payment or on a
separate check. If the licensed insurer or managed care plan combines interest
payments for more than one late clean claim, the check shall include
information listing each claim covered by the check and the specific amount of
interest being paid for each claim.
(d) Claims paid by a licensed insurer or
managed care plan are considered clean claims and are subject to the interest
provisions of the act. If a paid claim is re-adjudicated by the licensed
insurer or managed care plan, a new 45-day period for the prompt payment
provision begins again at the time additional information prompting the
readjudication is provided to the plan. Additional moneys which are owed or
paid to the health care provider are subject to the prompt payment provisions
of the act and this chapter. The prompt payment requirement of the act also
applies to the uncontested portion of a contested claim. A contested claim is a
claim for which required substantiating documentation for the entire claim has
been supplied to the licensed insurer or managed care plan, but the licensed
insurer or managed care plan has determined that it is not obligated to make
payment.
(e) Licensed insurers and
managed care plans shall provide written disclosure to health care providers of
all the data elements necessary to insure that a claim is without defect or
impropriety and meets the definition of clean claim under the act.
(1) Licensed insurers and managed care plans
shall provide this information to currently participating health care providers
by April 10, 2000. For health care providers entering into a participation
agreement with the licensed insurer or managed care plan after March 11, 2000,
the licensed insurer or managed care plan shall provide this information within
30 days of the parties entering into a participation agreement. If changes are
made to the required data elements, this information shall be provided to
participating health care providers at least 30 days before the effective date
of the changes.
(2) For
nonparticipating health care providers, a licensed insurer or managed care plan
shall provide this information within 45 days of an oral or written request
from the health care provider.
(f) Prior to filing a complaint with the
Department, health care providers who believe that a licensed insurer or
managed care plan has not paid a clean claim in accordance with the act and
this chapter shall first contact the licensed insurer or managed care plan to
determine the status of the claim, to ensure that sufficient documentation
supporting the claim has been provided, and to determine whether the claim is
considered by the licensed insurer or the managed care plan to be a clean
claim. Licensed insurers and managed care plans shall respond to the health
care provider's inquiries regarding the status of unpaid claims within 45 days
of submission of the claim or within 30 days of the inquiry, if the inquiry is
made after the 45-day period.
(g)
Health care providers may file a complaint, either individually or in batches,
with the Department prior to receipt of a determination from a licensed insurer
or managed care plan as to whether a claim is considered a clean claim if one
of the following applies:
(1) The licensed
insurer or managed care plan has not responded to a health care provider's
inquiries regarding the status of an unpaid claim within 45 days of submission
of the claim or within 30 days of the inquiry, if the inquiry is made after the
45-day period.
(2) The health care
provider believes that the licensed insurer or managed care plan is otherwise
not complying with the prompt payment provisions of the act.
(h) Complaints to the Department
regarding the prompt payment of claims by a licensed insurer or managed care
plan under the act and this chapter shall contain the following information:
(1) The provider's name, identification
number, address and daytime telephone number and the claim number.
(2) The name and address of the licensed
insurer or managed care plan.
(3)
The name of the patient and employer (if known).
(4) The dates of service and the dates the
claims were submitted to the licensed insurer or managed care plan.
(5) Relevant correspondence between the
provider and the licensed insurer or managed care plan, including requests for
additional information from the licensed insurer or managed care
plan.
(6) Additional information
which the provider believes would be of assistance in the Department's
review.
(7) Any additional
information pertinent to the complaint as requested by the
Commissioner.
(i) This
chapter does not prevent the Department from investigating a complaint when the
health care provider has failed to contact the licensed insurer or managed care
plan as provided for in subsection (f).
Notes
This section cited in 28 Pa. Code § 9.722 (relating to plan and health care provider contracts).
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