Reimbursement of claims, duties of health carriers--claims submittedin electronic format, when--compliance monitored bydepartment--complaint procedures developed--standard medical codesets required, when--rulemaking authority.
376.384. 1. All health carriers shall:
(1) Permit nonparticipating health care providers to file a claim forreimbursement for a health care service provided in this state as defined insection 376.1350 for a period of up to one year from the date of service;
(2) Permit participating health care providers to file a claim forreimbursement for a health care service provided in this state for a period ofup to six months from the date of service, unless the contract between thehealth carrier and health care provider specifies a different standard;
(3) Not request a refund or offset against a claim more than twelvemonths after a health carrier has paid a claim except in cases of fraud ormisrepresentation by the health care provider;
(4) Issue within one working day a confirmation of receipt of anelectronically filed claim.
2. On or after January 1, 2003, all claims for reimbursement for ahealth care service provided in this shall be submitted in an electronicformat consistent with federal administrative simplification standards adoptedpursuant to the Health Insurance Portability and Accountability Act of 1996.Any claim submitted by a health care provider after January 1, 2003, in anonelectronic format shall not be subject to the provisions of section376.383. Any health carrier shall provide readily accessible electronicfiling after this date to health care providers.
3. On or after January 1, 2002, the director of the department ofinsurance, financial institutions and professional registration shall monitorhealth carrier compliance with the provisions of this section and section376.383. Examinations, which may be based upon statistical samplings, todetermine compliance may be conducted by the department or the director maycontract with a qualified private entity. Compliance shall be defined asproperly processing and paying ninety-five percent of all claims received in agiven calendar year in accordance with the provisions of this section andsection 376.383. The director may assess an administrative penalty inaddition to the penalties outlined in section 376.383 of up to twenty-fivedollars per claim for the percentage of claims found to be in noncompliance,but not to exceed an annual aggregate penalty of two hundred fifty thousanddollars, for any health carrier deemed to be not in* compliance with thissection and section 376.383. Any penalty assessed pursuant to this subsectionshall be assessed in addition to penalties provided for pursuant to sections375.942 and 375.1012, RSMo.
4. If the director finds that health carriers are failing to makeinterest payments to health care professionals authorized by section 376.383,the director is authorized to order such health carriers to remit suchinterest payments. The director is also authorized to assess a monetarypenalty, payable to the state of Missouri, in a sum not to exceed twenty-fivepercent of the unpaid interest payment against health carriers.
5. A health carrier may request a waiver of the requirements of thissection and section 376.383 if the basis for the request is an act of God orother good cause as determined by the director.
6. The director shall develop a method by which health care providersmay submit complaints to the department identifying violations of this sectionand section 376.383 by a health carrier. The director shall consider suchcomplaints when determining whether to examine a health carrier's compliance.Prior to filing a complaint with the department, health care providers whobelieve that a health carrier has not paid a claim in accordance with thissection and section 376.383 shall first contact the health carrier todetermine the status of the claim to ensure that sufficient documentationsupporting the claim has been provided and to determine whether the claim isconsidered to be complete. Complaints to the department regarding the paymentof claims by a health carrier should contain information such as:
(1) The health care provider's name, address, and daytime phone number;
(2) The health carrier's name;
(3) The dates of service and the dates the claims were filed with thehealth carrier;
(4) Relevant correspondence between the health care provider and thehealth carrier, including requests from the health carrier for additionalinformation; and
(5) Additional information which the health care provider believes wouldbe of assistance in the department's review.
7. On or after January 1, 2003, all claims submitted electronically forreimbursement for a health care service provided in this state shall besubmitted in a uniform format utilizing standard medical code sets. Theuniform format and the standard medical code sets shall be promulgated by thedepartment of insurance, financial institutions and professional registrationthrough rules consistent with but no more stringent than the federaladministrative simplification standards adopted pursuant to the HealthInsurance Portability and Accountability Act of 1996.
8. The department shall have authority to promulgate rules for theimplementation of section 376.383 and this section. Any rule or portion of arule, as that term is defined in section 536.010, RSMo, that is created underthe authority delegated in this section shall become effective only if itcomplies with and is subject to all of the provisions of chapter 536, RSMo,and if applicable, sections 536.028, RSMo. This section and chapter 536,RSMo, are nonseverable and if any of the powers vested with the generalassembly pursuant to chapter 536, RSMo, to review, to delay the effective dateor to disapprove and annul a rule subsequently held unconstitutional, then thegrant of rulemaking authority and any rule proposed or adopted after August28, 2001, shall be invalid and void.
Reimbursement of claims, duties of health carriers--claims submittedin electronic format, when--compliance monitored bydepartment--complaint procedures developed--standard medical codesets required, when--rulemaking authority.
376.384. 1. All health carriers shall:
(1) Permit nonparticipating health care providers to file a claim forreimbursement for a health care service provided in this state as defined insection 376.1350 for a period of up to one year from the date of service;
(2) Permit participating health care providers to file a claim forreimbursement for a health care service provided in this state for a period ofup to six months from the date of service, unless the contract between thehealth carrier and health care provider specifies a different standard;
(3) Not request a refund or offset against a claim more than twelvemonths after a health carrier has paid a claim except in cases of fraud ormisrepresentation by the health care provider;
(4) Issue within one working day a confirmation of receipt of anelectronically filed claim.
2. On or after January 1, 2003, all claims for reimbursement for ahealth care service provided in this shall be submitted in an electronicformat consistent with federal administrative simplification standards adoptedpursuant to the Health Insurance Portability and Accountability Act of 1996.Any claim submitted by a health care provider after January 1, 2003, in anonelectronic format shall not be subject to the provisions of section376.383. Any health carrier shall provide readily accessible electronicfiling after this date to health care providers.
3. On or after January 1, 2002, the director of the department ofinsurance, financial institutions and professional registration shall monitorhealth carrier compliance with the provisions of this section and section376.383. Examinations, which may be based upon statistical samplings, todetermine compliance may be conducted by the department or the director maycontract with a qualified private entity. Compliance shall be defined asproperly processing and paying ninety-five percent of all claims received in agiven calendar year in accordance with the provisions of this section andsection 376.383. The director may assess an administrative penalty inaddition to the penalties outlined in section 376.383 of up to twenty-fivedollars per claim for the percentage of claims found to be in noncompliance,but not to exceed an annual aggregate penalty of two hundred fifty thousanddollars, for any health carrier deemed to be not in* compliance with thissection and section 376.383. Any penalty assessed pursuant to this subsectionshall be assessed in addition to penalties provided for pursuant to sections375.942 and 375.1012, RSMo.
4. If the director finds that health carriers are failing to makeinterest payments to health care professionals authorized by section 376.383,the director is authorized to order such health carriers to remit suchinterest payments. The director is also authorized to assess a monetarypenalty, payable to the state of Missouri, in a sum not to exceed twenty-fivepercent of the unpaid interest payment against health carriers.
5. A health carrier may request a waiver of the requirements of thissection and section 376.383 if the basis for the request is an act of God orother good cause as determined by the director.
6. The director shall develop a method by which health care providersmay submit complaints to the department identifying violations of this sectionand section 376.383 by a health carrier. The director shall consider suchcomplaints when determining whether to examine a health carrier's compliance.Prior to filing a complaint with the department, health care providers whobelieve that a health carrier has not paid a claim in accordance with thissection and section 376.383 shall first contact the health carrier todetermine the status of the claim to ensure that sufficient documentationsupporting the claim has been provided and to determine whether the claim isconsidered to be complete. Complaints to the department regarding the paymentof claims by a health carrier should contain information such as:
(1) The health care provider's name, address, and daytime phone number;
(2) The health carrier's name;
(3) The dates of service and the dates the claims were filed with thehealth carrier;
(4) Relevant correspondence between the health care provider and thehealth carrier, including requests from the health carrier for additionalinformation; and
(5) Additional information which the health care provider believes wouldbe of assistance in the department's review.
7. On or after January 1, 2003, all claims submitted electronically forreimbursement for a health care service provided in this state shall besubmitted in a uniform format utilizing standard medical code sets. Theuniform format and the standard medical code sets shall be promulgated by thedepartment of insurance, financial institutions and professional registrationthrough rules consistent with but no more stringent than the federaladministrative simplification standards adopted pursuant to the HealthInsurance Portability and Accountability Act of 1996.
8. The department shall have authority to promulgate rules for theimplementation of section 376.383 and this section. Any rule or portion of arule, as that term is defined in section 536.010, RSMo, that is created underthe authority delegated in this section shall become effective only if itcomplies with and is subject to all of the provisions of chapter 536, RSMo,and if applicable, sections 536.028, RSMo. This section and chapter 536,RSMo, are nonseverable and if any of the powers vested with the generalassembly pursuant to chapter 536, RSMo, to review, to delay the effective dateor to disapprove and annul a rule subsequently held unconstitutional, then thegrant of rulemaking authority and any rule proposed or adopted after August28, 2001, shall be invalid and void.
Reimbursement of claims, duties of health carriers--claims submittedin electronic format, when--compliance monitored bydepartment--complaint procedures developed--standard medical codesets required, when--rulemaking authority.
376.384. 1. All health carriers shall:
(1) Permit nonparticipating health care providers to file a claim forreimbursement for a health care service provided in this state as defined insection 376.1350 for a period of up to one year from the date of service;
(2) Permit participating health care providers to file a claim forreimbursement for a health care service provided in this state for a period ofup to six months from the date of service, unless the contract between thehealth carrier and health care provider specifies a different standard;
(3) Not request a refund or offset against a claim more than twelvemonths after a health carrier has paid a claim except in cases of fraud ormisrepresentation by the health care provider;
(4) Issue within one working day a confirmation of receipt of anelectronically filed claim.
2. On or after January 1, 2003, all claims for reimbursement for ahealth care service provided in this shall be submitted in an electronicformat consistent with federal administrative simplification standards adoptedpursuant to the Health Insurance Portability and Accountability Act of 1996.Any claim submitted by a health care provider after January 1, 2003, in anonelectronic format shall not be subject to the provisions of section376.383. Any health carrier shall provide readily accessible electronicfiling after this date to health care providers.
3. On or after January 1, 2002, the director of the department ofinsurance, financial institutions and professional registration shall monitorhealth carrier compliance with the provisions of this section and section376.383. Examinations, which may be based upon statistical samplings, todetermine compliance may be conducted by the department or the director maycontract with a qualified private entity. Compliance shall be defined asproperly processing and paying ninety-five percent of all claims received in agiven calendar year in accordance with the provisions of this section andsection 376.383. The director may assess an administrative penalty inaddition to the penalties outlined in section 376.383 of up to twenty-fivedollars per claim for the percentage of claims found to be in noncompliance,but not to exceed an annual aggregate penalty of two hundred fifty thousanddollars, for any health carrier deemed to be not in* compliance with thissection and section 376.383. Any penalty assessed pursuant to this subsectionshall be assessed in addition to penalties provided for pursuant to sections375.942 and 375.1012, RSMo.
4. If the director finds that health carriers are failing to makeinterest payments to health care professionals authorized by section 376.383,the director is authorized to order such health carriers to remit suchinterest payments. The director is also authorized to assess a monetarypenalty, payable to the state of Missouri, in a sum not to exceed twenty-fivepercent of the unpaid interest payment against health carriers.
5. A health carrier may request a waiver of the requirements of thissection and section 376.383 if the basis for the request is an act of God orother good cause as determined by the director.
6. The director shall develop a method by which health care providersmay submit complaints to the department identifying violations of this sectionand section 376.383 by a health carrier. The director shall consider suchcomplaints when determining whether to examine a health carrier's compliance.Prior to filing a complaint with the department, health care providers whobelieve that a health carrier has not paid a claim in accordance with thissection and section 376.383 shall first contact the health carrier todetermine the status of the claim to ensure that sufficient documentationsupporting the claim has been provided and to determine whether the claim isconsidered to be complete. Complaints to the department regarding the paymentof claims by a health carrier should contain information such as:
(1) The health care provider's name, address, and daytime phone number;
(2) The health carrier's name;
(3) The dates of service and the dates the claims were filed with thehealth carrier;
(4) Relevant correspondence between the health care provider and thehealth carrier, including requests from the health carrier for additionalinformation; and
(5) Additional information which the health care provider believes wouldbe of assistance in the department's review.
7. On or after January 1, 2003, all claims submitted electronically forreimbursement for a health care service provided in this state shall besubmitted in a uniform format utilizing standard medical code sets. Theuniform format and the standard medical code sets shall be promulgated by thedepartment of insurance, financial institutions and professional registrationthrough rules consistent with but no more stringent than the federaladministrative simplification standards adopted pursuant to the HealthInsurance Portability and Accountability Act of 1996.
8. The department shall have authority to promulgate rules for theimplementation of section 376.383 and this section. Any rule or portion of arule, as that term is defined in section 536.010, RSMo, that is created underthe authority delegated in this section shall become effective only if itcomplies with and is subject to all of the provisions of chapter 536, RSMo,and if applicable, sections 536.028, RSMo. This section and chapter 536,RSMo, are nonseverable and if any of the powers vested with the generalassembly pursuant to chapter 536, RSMo, to review, to delay the effective dateor to disapprove and annul a rule subsequently held unconstitutional, then thegrant of rulemaking authority and any rule proposed or adopted after August28, 2001, shall be invalid and void.
