§ 27-18-61. Prompt processing of claims.
(a) A healthcare entity or health plan operating in the state shall pay all complete claims
for covered healthcare services submitted to the healthcare entity or health plan
by a healthcare provider or by a policyholder within forty (40) calendar days following
the date of receipt of a complete written claim or within thirty (30) calendar days
following the date of receipt of a complete electronic claim. Each health plan shall
establish a written standard defining what constitutes a complete claim and shall
distribute this standard to all participating providers.
(b) If the healthcare entity or health plan denies or pends a claim, the healthcare entity
or health plan shall have thirty (30) calendar days from receipt of the claim to notify
in writing the healthcare provider or policyholder of any and all reasons for denying
or pending the claim and what, if any, additional information is required to process
the claim. No healthcare entity or health plan may limit the time period in which
additional information may be submitted to complete a claim.
(c) Any claim that is resubmitted by a healthcare provider or policyholder shall be treated
by the healthcare entity or health plan pursuant to the provisions of subsection (a)
of this section.
(d) A healthcare entity or health plan that fails to reimburse the healthcare provider
or policyholder after receipt by the healthcare entity or health plan of a complete
claim within the required timeframes shall pay to the healthcare provider or the policyholder
who submitted the claim, in addition to any reimbursement for healthcare services
provided, interest which shall accrue at the rate of twelve percent (12%) per annum
commencing on the thirty-first (31st) day after receipt of a complete electronic claim
or on the forty-first (41st) day after receipt of a complete written claim, and ending
on the date the payment is issued to the healthcare provider or the policyholder.
(e) Exceptions to the requirements of this section are as follows:
(1) No healthcare entity or health plan operating in the state shall be in violation of
this section for a claim submitted by a healthcare provider or policyholder if:
(i) Failure to comply is caused by a directive from a court or federal or state agency;
(ii) The healthcare entity or health plan is in liquidation or rehabilitation or is operating
in compliance with a court-ordered plan of rehabilitation; or
(iii) The healthcare entity or health plan's compliance is rendered impossible due to matters
beyond its control that are not caused by it.
(2) No healthcare entity or health plan operating in the state shall be in violation of
this section for any claim: (i) Initially submitted more than ninety (90) days after
the service is rendered, or (ii) Resubmitted more than ninety (90) days after the
date the healthcare provider received the notice provided for in subsection (b) of
this section; provided, this exception shall not apply in the event compliance is
rendered impossible due to matters beyond the control of the healthcare provider and
were not caused by the healthcare provider.
(3) No healthcare entity or health plan operating in the state shall be in violation of
this section while the claim is pending due to a fraud investigation by a state or
federal agency.
(4) No healthcare entity or health plan operating in the state shall be obligated under
this section to pay interest to any healthcare provider or policyholder for any claim
if the director of business regulation finds that the entity or plan is in substantial
compliance with this section. A healthcare entity or health plan seeking such a finding
from the director shall submit any documentation that the director shall require.
A healthcare entity or health plan that is found to be in substantial compliance with
this section shall thereafter submit any documentation that the director may require
on an annual basis for the director to assess ongoing compliance with this section.
(5) A healthcare entity or health plan may petition the director for a waiver of the provision
of this section for a period not to exceed ninety (90) days in the event the healthcare
entity or health plan is converting or substantially modifying its claims processing
systems.
(f) For purposes of this section, the following definitions apply:
(1) "Claim� means: (i) A bill or invoice for covered services; (ii) A line item of service;
or (iii) All services for one patient or subscriber within a bill or invoice.
(2) "Date of receipt� means the date the healthcare entity or health plan receives the
claim whether via electronic submission or as a paper claim.
(3) "Healthcare entity� means a licensed insurance company or nonprofit hospital or medical
or dental service corporation or plan or health maintenance organization, or a contractor
as described in § 23-17.13-2(2) [repealed], that operates a health plan.
(4) "Healthcare provider� means an individual clinician, either in practice independently
or in a group, who provides healthcare services, and otherwise referred to as a non-institutional
provider.
(5) "Healthcare services� include, but are not limited to, medical, mental health, substance
abuse, dental, and any other services covered under the terms of the specific health
plan.
(6) "Health plan� means a plan operated by a healthcare entity that provides for the delivery
of healthcare services to persons enrolled in those plans through:
(i) Arrangements with selected providers to furnish healthcare services; and/or
(ii) Financial incentive for persons enrolled in the plan to use the participating providers
and procedures provided for by the health plan.
(7) "Policyholder� means a person covered under a health plan or a representative designated
by that person.
(8) "Substantial compliance� means that the healthcare entity or health plan is processing
and paying ninety-five percent (95%) or more of all claims within the time frame provided
for in subsections (a) and (b) of this section.
(g) Any provision in a contract between a healthcare entity or a health plan and a healthcare
provider that is inconsistent with this section shall be void and of no force and
effect.