A.
(1)Any nonelectronic claim for payment for prescription drugs, other products and supplies, and pharmacist services submitted by a pharmacist or pharmacy within forty-five days of the date of service under a contract for provision of covered benefits with a health insurance issuer shall be paid not more than forty-five days from the date upon which a correctly completed uniform claim form is furnished, unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(2)Any nonelectronic claim for payment for prescription drugs, other products and supplies, and pharmacist services submitted by a pharmacist or pharmacy under a contract for provision of covered benefits with a health insurance issuer more than forty-five days after the date of
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A.(1) Any nonelectronic claim for payment for prescription drugs, other products and supplies, and pharmacist services submitted by a pharmacist or pharmacy within forty-five days of the date of service under a contract for provision of covered benefits with a health insurance issuer shall be paid not more than forty-five days from the date upon which a correctly completed uniform claim form is furnished, unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(2) Any nonelectronic claim for payment for prescription drugs, other products and supplies, and pharmacist services submitted by a pharmacist or pharmacy under a contract for provision of covered benefits with a health insurance issuer more than forty-five days after the date of service or resubmitted because the original claim was incomplete shall be paid not more than sixty days from the date upon which a correctly completed uniform claim form is furnished, unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(3) Any other nonelectronic claim for payment for prescription drugs, other products and supplies, and pharmacist services, whether submitted for payment by an insured or enrollee or submitted by a pharmacist or pharmacy rendering covered services that are not otherwise payable to the pharmacist or pharmacy under contract with the health insurance issuer, shall be paid not more than thirty days from the date upon which a correctly completed uniform claim form is furnished to the health insurance issuer, unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
B.(1) Health insurance issuers shall have appropriate handling procedures approved by the department for the acceptance of nonelectronic claim submissions. Such procedures shall include:
(a) A process for documenting the date of actual receipt of nonelectronic claims.
(b) A process for reviewing nonelectronic claims for accuracy and acceptability.
(2) Such procedures shall assure that all such nonelectronic claims received are reviewed for correct completion within a reasonable period of time.
(3) For any nonelectronic claim that is found to be incomplete or otherwise not payable, the health insurance issuer shall provide written notice of the reasons that the claim cannot be processed for payment within two business days from the date of reviewing such claim for completion.
C. Health insurance issuers shall establish appropriate procedures approved by the department to assure that any claimant who is not paid within the time frames specified in this Section receives a late payment adjustment equal to one percent of the amount due. For any period greater than twenty-five days following the time frames specified in this Section, the health insurance issuer shall pay an additional late payment adjustment equal to one percent of the unpaid balance due for each month or partial month that such claim remains unpaid.
D. Health insurance issuers shall have appropriate procedures approved by the department to assure compliance with this Subpart. Such procedures shall include but shall not be limited to a plan for the acceptance of nonelectronic claim submissions to document the actual date of receipt and to prevent the loss of such claims.