Section 154.18. Prompt payment

(a) Licensed insurers and managed care plans shall pay clean claims and the uncontested portions of a contested claim under subsection (d) submitted by a health care provider for services provided on or after January 1, 1999, within 45 days of the licensed insurer’s or managed care plan’s receipt of the claim from the health care provider. The prompt payment provision applies only to claims submitted under health insurance policies, excluding areas such as automobile and worker’s compensation policies.

(b) For purposes of prompt payment, a claim shall be deemed to have been ‘‘paid’’ upon one of the following:

(1) A check is mailed by the licensed insurer or managed care plan to the health care provider.

(2) An electronic transfer of funds is made from the licensed insurer or managed care plan to the health care provider.

(c) Interest due to a health care provider on a clean claim shall be calculated and paid by the licensed insurer or managed care plan to the health care provider and shall be added to the amount owed on the clean claim. The interest shall be paid within 30 days of the payment of the claim. Interest owed of less than $2 on a single claim does not have to be paid by the licensed insurer or managed care plan. Interest can be paid on the same check as the claim payment or on a separate check. If the licensed insurer or managed care plan combines interest payments for more than one late clean claim, the check shall include information listing each claim covered by the check and the specific amount of interest being paid for each claim.

(d) Claims paid by a licensed insurer or managed care plan are considered clean claims and are subject to the interest provisions of the act. If a paid claim is re-adjudicated by the licensed insurer or managed care plan, a new 45-day period for the prompt payment provision begins again at the time additional information prompting the readjudication is provided to the plan. Additional moneys which are owed or paid to the health care provider are subject to the prompt payment provisions of the act and this chapter. The prompt payment requirement of the act also applies to the uncontested portion of a contested claim. A contested claim is a claim for which required substantiating documentation for the entire claim has been supplied to the licensed insurer or managed care plan, but the licensed insurer or managed care plan has determined that it is not obligated to make payment.

(e) Licensed insurers and managed care plans shall provide written disclosure to health care providers of all the data elements necessary to insure that a claim is without defect or impropriety and meets the definition of clean claim under the act.

(1) Licensed insurers and managed care plans shall provide this information to currently participating health care providers by April 10, 2000. For health care providers entering into a participation agreement with the licensed insurer or managed care plan after March 11, 2000, the licensed insurer or managed care plan shall provide this information within 30 days of the parties entering into a participation agreement. If changes are made to the required data elements, this information shall be provided to participating health care providers at least 30 days before the effective date of the changes.

(2) For nonparticipating health care providers, a licensed insurer or managed care plan shall provide this information within 45 days of an oral or written request from the health care provider.

(f) Prior to filing a complaint with the Department, health care providers who believe that a licensed insurer or managed care plan has not paid a clean claim in accordance with the act and this chapter shall first contact the licensed insurer or managed care plan to determine the status of the claim, to ensure that sufficient documentation supporting the claim has been provided, and to determine whether the claim is considered by the licensed insurer or the managed care plan to be a clean claim. Licensed insurers and managed care plans shall respond to the health care provider’s inquiries regarding the status of unpaid claims within 45 days of submission of the claim or within 30 days of the inquiry, if the inquiry is made after the 45-day period.

(g) Health care providers may file a complaint, either individually or in batches, with the Department prior to receipt of a determination from a licensed insurer or managed care plan as to whether a claim is considered a clean claim if one of the following applies:

(1) The licensed insurer or managed care plan has not responded to a health care provider’s inquiries regarding the status of an unpaid claim within 45 days of submission of the claim or within 30 days of the inquiry, if the inquiry is made after the 45-day period.

(2) The health care provider believes that the licensed insurer or managed care plan is otherwise not complying with the prompt payment provisions of the act.

(h) Complaints to the Department regarding the prompt payment of claims by a licensed insurer or managed care plan under the act and this chapter shall contain the following information:

(1) The provider’s name, identification number, address and daytime telephone number and the claim number.

(2) The name and address of the licensed insurer or managed care plan.

(3) The name of the patient and employer (if known).

(4) The dates of service and the dates the claims were submitted to the licensed insurer or managed care plan.

(5) Relevant correspondence between the provider and the licensed insurer or managed care plan, including requests for additional information from the licensed insurer or managed care plan.

(6) Additional information which the provider believes would be of assistance in the Department’s review.

(7) Any additional information pertinent to the complaint as requested by the Commissioner.

(i) This chapter does not prevent the Department from investigating a complaint when the health care provider has failed to contact the licensed insurer or managed care plan as provided for in subsection (f).

Notation

Notes of Decisions

Private Action

Because there is no indication in the regulations that a private right of action exists, and because those same regulations provided a system of enforcement by the Insurance Department, the court held that there is not private cause of action for violation of the prompt payment provisions of the Health Care Act (40 P. S. § 991.2101 et seq.) Solomon v. United States Healthcare Systems of Pennsylvania, 797 A.2d 346 (Pa. Super. 2002); appeal denied 808 A.2d 573 (Pa. 2002).

Cross References

This section cited in 28 Pa. Code § 9.722 (relating to plan and health care provider contracts).