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



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



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



(d)  Every entity shall implement and make
accessible to providers a system that provides verification of enrollee
eligibility under plans offered by the entity.



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



(f)  Payment of a claim under this section
shall 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 the
contrary, interest shall be allowed at a rate of fifteen per cent a year for
money owed by an entity on payment of a claim exceeding the applicable time
limitations under this section, as follows:



(1)  For an uncontested claim:



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



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



(2)  For a contested claim filed in writing:



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



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



(3)  For a contested claim filed electronically:



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



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



The commissioner may suspend the accrual of interest
if the commissioner determines that the entity's failure to pay a claim within
the applicable time limitations was the result of a major disaster or of an
unanticipated major computer system failure.



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



(i)  In determining the penalties under section
431:13-201 for a violation of this section, the commissioner shall consider:



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



(2)  The gravity of the violation;



(3)  The history of the entity for previous similar
violations;



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



(5)  Any other relevant factors bearing upon the
violation.



(j)  As used in this section:



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



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



(1)  The claim is for a covered health care service
provided by an eligible health care provider to a covered person under the
contract;



(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 claim
was submitted fraudulently.



The term does not include:



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



(2)  Claims that are submitted fraudulently or that
are 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 involve
third-party liability.



"Contest", "contesting", or
"contested" means the circumstances under which an entity was not
provided with, or did not have reasonable access to, sufficient information
needed 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 to
pay 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 or
sickness insurance providers under part I of article 10A of chapter 431, mutual
benefit societies under article 1 of chapter 432, dental service corporations
under chapter 423, and health maintenance organizations under chapter 432D.



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



"Health care provider" means a Hawaii
health care facility, physician, nurse, or any other provider of health care
services 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 care
facility" is repealed.