1371.35
. (a) A health care service plan, including a specialized
health care service plan, shall reimburse each complete claim, or
portion thereof, whether in state or out of state, as soon as
practical, but no later than 30 working days after receipt of the
complete claim by the health care service plan, or if the health care
service plan is a health maintenance organization, 45 working days
after receipt of the complete claim by the health care service plan.
However, a plan may contest or deny a claim, or portion thereof, by
notifying the claimant, in writing, that the claim is contested or
denied, within 30 working days after receipt of the claim by the
health care service plan, or if the health care service plan is a
health maintenance organization, 45 working days after receipt of the
claim by the health care service plan. The notice that a claim, or
portion thereof, is contested shall identify the portion of the claim
that is contested, by revenue code, and the specific information
needed from the provider to reconsider the claim. The notice that a
claim, or portion thereof, is denied shall identify the portion of
the claim that is denied, by revenue code, and the specific reasons
for the denial. A plan may delay payment of an uncontested portion of
a complete claim for reconsideration of a contested portion of that
claim so long as the plan pays those charges specified in subdivision
(b).
(b) If a complete claim, or portion thereof, that is neither
contested nor denied, is not reimbursed by delivery to the claimant's
address of record within the respective 30 or 45 working days after
receipt, the plan shall pay the greater of fifteen dollars ($15) per
year or interest at the rate of 15 percent per annum beginning with
the first calendar day after the 30- or 45-working-day period. A
health care service plan shall automatically include the fifteen
dollars ($15) per year or interest due in the payment made to the
claimant, without requiring a request therefor.
(c) For the purposes of this section, a claim, or portion thereof,
is reasonably contested if the plan has not received the completed
claim. A paper claim from an institutional provider shall be deemed
complete upon submission of a legible emergency department report and
a completed UB 92 or other format adopted by the National Uniform
Billing Committee, and reasonable relevant information requested by
the plan within 30 working days of receipt of the claim. An
electronic claim from an institutional provider shall be deemed
complete upon submission of an electronic equivalent to the UB 92 or
other format adopted by the National Uniform Billing Committee, and
reasonable relevant information requested by the plan within 30
working days of receipt of the claim. However, if the plan requests a
copy of the emergency department report within the 30 working days
after receipt of the electronic claim from the institutional
provider, the plan may also request additional reasonable relevant
information within 30 working days of receipt of the emergency
department report, at which time the claim shall be deemed complete.
A claim from a professional provider shall be deemed complete upon
submission of a completed HCFA 1500 or its electronic equivalent or
other format adopted by the National Uniform Billing Committee, and
reasonable relevant information requested by the plan within 30
working days of receipt of the claim. The provider shall provide the
plan reasonable relevant information within 10 working days of
receipt of a written request that is clear and specific regarding the
information sought. If, as a result of reviewing the reasonable
relevant information, the plan requires further information, the plan
shall have an additional 15 working days after receipt of the
reasonable relevant information to request the further information,
notwithstanding any time limit to the contrary in this section, at
which time the claim shall be deemed complete.
(d) This section shall not apply to claims about which there is
evidence of fraud and misrepresentation, to eligibility
determinations, or in instances where the plan has not been granted
reasonable access to information under the provider's control. A plan
shall specify, in a written notice sent to the provider within the
respective 30- or 45-working days of receipt of the claim, which, if
any, of these exceptions applies to a claim.
(e) If a claim or portion thereof is contested on the basis that
the plan has not received information reasonably necessary to
determine payer liability for the claim or portion thereof, then the
plan shall have 30 working days or, if the health care service plan
is a health maintenance organization, 45 working days after receipt
of this additional information to complete reconsideration of the
claim. If a claim, or portion thereof, undergoing reconsideration is
not reimbursed by delivery to the claimant's address of record within
the respective 30 or 45 working days after receipt of the additional
information, the plan shall pay the greater of fifteen dollars ($15)
per year or interest at the rate of 15 percent per annum beginning
with the first calendar day after the 30- or 45-working-day period. A
health care service plan shall automatically include the fifteen
dollars ($15) per year or interest due in the payment made to the
claimant, without requiring a request therefor.
(f) The obligation of the plan to comply with this section shall
not be deemed to be waived when the plan requires its medical groups,
independent practice associations, or other contracting entities to
pay claims for covered services. This section shall not be construed
to prevent a plan from assigning, by a written contract, the
responsibility to pay interest and late charges pursuant to this
section to medical groups, independent practice associations, or
other entities.
(g) A plan shall not delay payment on a claim from a physician or
other provider to await the submission of a claim from a hospital or
other provider, without citing specific rationale as to why the delay
was necessary and providing a monthly update regarding the status of
the claim and the plan's actions to resolve the claim, to the
provider that submitted the claim.
(h) A health care service plan shall not request or require that a
provider waive its rights pursuant to this section.
(i) This section shall not apply to capitated payments.
(j) This section shall apply only to claims for services rendered
to a patient who was provided emergency services and care as defined
in Section 1317.1 in the United States on or after September 1, 1999.
(k) This section shall not be construed to affect the rights or
obligations of any person pursuant to Section 1371.
( l) This section shall not be construed to affect a written
agreement, if any, of a provider to submit bills within a specified
time period.