20-3102

20-3102. Timely payment of health care
providers' claims; grievances

A. A health care insurer shall adjudicate any clean claim from a contracted or
noncontracted health care provider relating to health care insurance coverage within
thirty days after the health care insurer receives the clean claim or within the time
period specified by contract. Unless there is an express written contract between the
health care insurer and the health care provider that specifies the period in which
approved claims shall be paid, the health care insurer shall pay the approved portion of
any clean claim within thirty days after the claim is adjudicated. If the claim is not
paid within the thirty day period or within the time period specified in the contract,
the health care insurer shall pay interest on the claim at a rate that is equal to the
legal rate. Interest shall be calculated beginning on the date that the payment to the
health care provider is due.

B. If the claim is not a clean claim and the health care insurer requires
additional information to adjudicate the claim, the health care insurer shall send a
written request for additional information to the contracted or noncontracted health care
provider, enrollee or third party within thirty days after the health care insurer
receives the claim. The health care insurer shall notify the contracted or noncontracted
health care provider of all of the specific reasons for the delay in adjudicating the
claim. The health care insurer shall record the date it receives the additional
information and shall adjudicate the claim within thirty days after receiving all the
additional information. The health care insurer shall also pay the approved portion of
the adjudicated claim within the same thirty day period allowed for adjudication or
within the time period specified in the provider's contract. If the health care insurer
fails to pay the claim as prescribed in this subsection, the health care insurer shall
pay interest on the claim in the manner prescribed in subsection A.

C. A health care insurer shall not delay the payment of clean claims to a
contracted or noncontracted provider or pay less than the amount agreed to by contract to
a contracted health care provider without reasonable justification.

D. A health care insurer shall not request information from a contracted or
noncontracted health care provider that does not apply to the medical condition at issue
for the purposes of adjudicating a clean claim.

E. A health care insurer shall not request a contracted or noncontracted health
care provider to resubmit claim information that the contracted or noncontracted health
care provider can document it has already provided to the health care insurer unless the
health care insurer provides a reasonable justification for the request and the purpose
of the request is not to delay the payment of the claim.

F. A health care insurer shall establish an internal system for resolving payment
disputes and other contractual grievances with health care providers. The director may
review the health care insurer's internal system for resolving payment disputes and other
contractual grievances with health care providers. Each health care insurer shall
maintain records of health care provider grievances. Semiannually each health care
insurer shall provide the director with a summary of all records of health care provider
grievances received during the prior six months. The records shall include at least the
following information:

1. The name and any identification number of the health care provider who filed a
grievance.

2. The type of grievance.

3. The date the insurer received the grievance.

4. The date the grievance was resolved.

G. On review of the records, if the director finds a significant number of
grievances that have not been resolved, the director may examine the health care insurer.

H. This section does not require or authorize the director to adjudicate the
individual contracts or claims between health care insurers and health care providers.

I. Except in cases of fraud, a health care insurer or contracted or noncontracted
health care provider shall not adjust or request adjustment of the payment or denial of a
claim more than one year after the health care insurer has paid or denied that claim. If
the health care insurer and health care provider agree through contract on a length of
time to adjust or request adjustment of the payment of a claim, the health care insurer
and health care provider must have the same length of time to adjust or request
adjustment of the payment of the claim. If a claim is adjusted, neither the health care
insurer nor the health care provider shall owe interest on the overpayment or
underpayment resulting from the adjustment, as long as the adjusted payment is made or
recoupment taken within thirty days of the date of the claim adjustment.

J. This chapter does not apply to licensed health care providers who are salaried
employees of a health care insurer.

K. If a contracted or noncontracted health care provider files a claim or grievance
with a health care insurer that has changed the location where providers were instructed
to file claims or grievances, the health care insurer shall, for ninety days following
the change:

1. Consider a claim or grievance delivered to the original location properly
received.

2. Following receipt of a claim or grievance at the original location, promptly
notify the health care provider of the change of address through mailed written notice or
some other written communication.