Section 89.779. Standards for claims payment

(a) An issuer shall comply with section 1882(c)(3) of the Social Security Act (42 U.S.C.A. § 1395ss(c)(3) (as enacted by section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, the act of December 22, 1987 (Pub.L. No. 100, 101 Stat. 1330) by:

(1) Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of another claim form otherwise required and making a payment determination on the basis of the information contained in that notice.

(2) Notifying the participating physician or supplier and the beneficiary of the payment determination.

(3) Paying the participating physician or supplier directly.

(4) Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number and a central mailing address to which notices from a Medicare carrier may be sent.

(5) Paying user fees for claim notices that are transmitted electronically or otherwise.

(6) Providing to the Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.

(b) Compliance with the requirements in subsection (a) shall be certified on the Medicare supplement insurance experience reporting form.

The provisions of this § 89.779 adopted July 24, 1992, effective July 25, 1992, 22 Pa.B. 3841.

Notation

Cross References

This section cited in 31 Pa. Code § 89.771 (relating to applicability and scope).