A.
(1)Any nonelectronic claim by a health care provider under a contract with a health insurance issuer, for provision of health care services, submitted by the provider or its agent within forty-five days of the date of service, or date of discharge from a health care facility or institution, shall be paid, denied, or pended not more than forty-five days from the date upon which a nonelectronic clean claim is received by the issuer or its agent, unless it is not payable under the terms of the applicable contract of health insurance coverage or unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(2)Any nonelectronic claim by a health care provider under a contract with a health insurance issuer, for provision of health care service
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A.(1) Any nonelectronic claim by a health care provider under a contract with a health insurance issuer, for provision of health care services, submitted by the provider or its agent within forty-five days of the date of service, or date of discharge from a health care facility or institution, shall be paid, denied, or pended not more than forty-five days from the date upon which a nonelectronic clean claim is received by the issuer or its agent, unless it is not payable under the terms of the applicable contract of health insurance coverage or unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(2) Any nonelectronic claim by a health care provider under a contract with a health insurance issuer, for provision of health care services, submitted by the provider or its agent more than forty-five days after the date of service, or date of discharge from a health care facility or institution, or resubmitted because the original claim was not an accepted claim or not a clean claim shall be paid, denied, or pended not more than sixty days from the date upon which a nonelectronic clean claim is received by the issuer or its agent, unless it is not payable under the terms of the applicable contract of insurance or unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(3) Any other nonelectronic claim for health insurance coverage benefits submitted for payment by an enrollee or insured or by a noncontracted health care provider rendering covered health care services, or by the provider's agent, shall be paid, denied, or pended not more than forty-five days from the date upon which a nonelectronic clean claim is received by the issuer or its agent, unless it is not payable under the terms of the applicable contract of insurance or unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(4) For purposes of this Subsection, the issuer shall either provide written notice to the provider that a claim is pended or allow the provider Internet access to such information.
(5) Just and reasonable grounds, as used in this Subsection, shall include but not be limited to determination of whether the enrollee or insured was eligible for health insurance coverage on the date health care services were rendered.
B.(1) Health insurance issuers shall have appropriate procedures approved by the department to assure compliance with this Subpart. Health insurance issuers shall have appropriate handling procedures approved by the department for the acceptance of nonelectronic claim submissions. Such procedures shall include but not be limited to the following:
(a) A process for documenting the date of actual receipt of nonelectronic claims.
(b) A process for reviewing nonelectronic claims for accuracy and acceptability.
(c) A process for prevention of loss of such claims.
(2) Such procedures shall assure that all such claims received are reviewed for determination as to whether such claims are accepted or clean claims.
(3) The department may promulgate and adopt additional handling procedures consistent with this Section by rule pursuant to the Administrative Procedure Act.
C. Health insurance issuers shall establish appropriate procedures approved by the department to assure that any health care provider who is not paid within the time frames specified in this Section receives a late payment adjustment equal to twelve percent per annum of the amount due.
D. The provisions of this Subpart shall not apply to the Office of Group Benefits.