§431:13-108  Reimbursement for accident andhealth or sickness insurance benefits.  (a)  This section applies toaccident and health or sickness insurance providers under part I of article 10Aof chapter 431, mutual benefit societies under article 1 of chapter 432, dentalservice corporations under chapter 423, and health maintenance organizationsunder chapter 432D.

(b)  Unless shorter payment timeframes areotherwise specified in a contract, an entity shall reimburse a claim that isnot contested or denied not more than thirty calendar days after receiving theclaim filed in writing, or fifteen calendar days after receiving the claimfiled electronically, as appropriate.

(c)  If a claim is contested or denied orrequires more time for review by an entity, the entity shall notify the healthcare provider in writing or electronically not more than fifteen calendar daysafter receiving a claim filed in writing, or not more than seven calendar daysafter receiving a claim filed electronically, as appropriate.  The notice shallidentify the contested portion of the claim and the specific reason forcontesting or denying the claim, and may request additional information;provided that a notice shall not be required if the entity provides areimbursement report containing the information, at least monthly, to theprovider.

(d)  Every entity shall implement and makeaccessible to providers a system that provides verification of enrolleeeligibility under plans offered by the entity.

(e)  If information received pursuant to arequest for additional information is satisfactory to warrant paying the claim,the claim shall be paid not more than thirty calendar days after receiving theadditional information in writing, or not more than fifteen calendar days afterreceiving the additional information filed electronically, as appropriate.

(f)  Payment of a claim under this sectionshall be effective upon the date of the postmark of the mailing of the payment,or the date of the electronic transfer of the payment, as applicable.

(g)  Notwithstanding section 478-2 to thecontrary, interest shall be allowed at a rate of fifteen per cent a year formoney owed by an entity on payment of a claim exceeding the applicable timelimitations under this section, as follows:

(1)  For an uncontested claim:

(A)  Filed in writing, interest from the firstcalendar day after the thirty-day period in subsection (b); or

(B)  Filed electronically, interest from thefirst calendar day after the fifteen-day period in subsection (b);

(2)  For a contested claim filed in writing:

(A)  For which notice was provided undersubsection (c), interest from the first calendar day thirty days after the datethe additional information is received; or

(B)  For which notice was not provided withinthe time specified under subsection (c), interest from the first calendar dayafter the claim is received; or

(3)  For a contested claim filed electronically:

(A)  For which notice was provided undersubsection (c), interest from the first calendar day fifteen days after theadditional information is received; or

(B)  For which notice was not provided withinthe time specified under subsection (c), interest from the first calendar dayafter the claim is received.

The commissioner may suspend the accrual of interestif the commissioner determines that the entity's failure to pay a claim withinthe applicable time limitations was the result of a major disaster or of anunanticipated major computer system failure.

(h)  Any interest that accrues in a sum of atleast $2 on a delayed clean claim in this section shall be automatically addedby the entity to the amount of the unpaid claim due the provider.

(i)  In determining the penalties under section431:13-201 for a violation of this section, the commissioner shall consider:

(1)  The appropriateness of the penalty in relation tothe financial resources and good faith of the entity;

(2)  The gravity of the violation;

(3)  The history of the entity for previous similarviolations;

(4)  The economic benefit to be derived by the entityand the economic impact upon the health care facility or health care providerresulting from the violation; and

(5)  Any other relevant factors bearing upon theviolation.

(j)  As used in this section:

"Claim" means any claim, bill, orrequest for payment for all or any portion of health care services provided bya health care provider of services submitted by an individual or pursuant to acontract or agreement with an entity, using the entity's standard claim formwith all required fields completed with correct and complete information.

"Clean claim" means a claim in whichthe information in the possession of an entity adequately indicates that:

(1)  The claim is for a covered health care serviceprovided by an eligible health care provider to a covered person under thecontract;

(2)  The claim has no material defect or impropriety;

(3)  There is no dispute regarding the amount claimed;and

(4)  The payer has no reason to believe that the claimwas submitted fraudulently.

The term does not include:

(1)  Claims for payment of expenses incurred during aperiod of time when premiums were delinquent;

(2)  Claims that are submitted fraudulently or thatare based upon material misrepresentations;

(3)  Medicaid or Medigap claims; and

(4)  Claims that require a coordination of benefits,subrogation, or preexisting condition investigations, or that involvethird-party liability.

"Contest", "contesting", or"contested" means the circumstances under which an entity was notprovided with, or did not have reasonable access to, sufficient informationneeded to determine payment liability or basis for payment of the claim.

"Deny", "denying", or"denied" means the assertion by an entity that it has no liability topay a claim based upon eligibility of the patient, coverage of a service,medical necessity of a service, liability of another payer, or other grounds.

"Entity" means accident and health orsickness insurance providers under part I of article 10A of chapter 431, mutualbenefit societies under article 1 of chapter 432, dental service corporationsunder chapter 423, and health maintenance organizations under chapter 432D.

"Health care facility" shall have thesame meaning as in section 327D-2.

"Health care provider" means a Hawaiihealth care facility, physician, nurse, or any other provider of health careservices covered by an entity. [L 1999, c 99, §§2, 5; am L 2002, c 52, §§2, 3;am L 2003, c 212, §105]

 

Note

 

  Section 327D-2 referred to in definition of "health carefacility" is repealed.