SB78 (2005) Detail

Relative to payment of health care providers by health carriers.


CHAPTER 162

SB 78 – FINAL VERSION

25May2005… 1381h

2005 SESSION

05-0791

01/09

SENATE BILL 78

AN ACT relative to payment of health care providers by health carriers.

SPONSORS: Sen. Flanders, Dist 7; Sen. Clegg, Dist 14; Sen. Odell, Dist 8; Sen. Barnes, Dist 17; Sen. Martel, Dist 18; Rep. Hunt, Ches 7; Rep. S. Francoeur, Rock 15; Rep. MacKay, Merr 11

COMMITTEE: Banks and Insurance

ANALYSIS

This bill clarifies the procedure for the requirement of prompt payment to health insurance carriers and insured persons.

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Explanation: Matter added to current law appears in bold italics.

Matter removed from current law appears [in brackets and struckthrough.]

Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

25May2005… 1381h

05-0791

01/09

STATE OF NEW HAMPSHIRE

In the Year of Our Lord Two Thousand Five

AN ACT relative to payment of health care providers by health carriers.

Be it Enacted by the Senate and House of Representatives in General Court convened:

162:1 Individual Insurance; Prompt Payment. Amend RSA 415:6-h to read as follows:

415:6-h Prompt Payment Required.

I.(a) Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses for its insured persons shall pay for services rendered by New Hampshire health care providers within [45] 30 calendar days upon receipt of a clean [written] non-electronic claim or 15 calendar days upon receipt of a clean electronic claim.

(b) [If] When the insurer is denying or pending the claim, the insurer shall have 15 calendar days upon receipt of [the] an electronic claim or 30 days upon receipt of a non-electronic claim to notify the health care provider or certificate holder of the reason for denying or pending the claim and what, if any, additional information is required to [process] adjudicate the claim. Upon the insurer’s receipt of the requested additional information, the insurer shall adjudicate the claim within 45 calendar days. If the required notice is not provided, the claim shall be treated as a clean claim and shall be adjudicated pursuant to subparagraph (a).

(c) Payment of a claim shall be considered to be made on the date a check was issued or electronically transferred. The insurer shall mail checks no later than 5 business days after the date a check was issued. Failure to mail a check within 5 business days shall constitute a violation subject to enforcement under RSA 415:20.

(d) The insurer’s failure to comply with the time limits in this section shall not have the effect of requiring coverage for an otherwise non-covered claim. This section shall only apply to payments made on a claims basis and shall not apply to capitation or other forms of periodic payment.

II. In this section:

(a) “Clean claim” means a claim for payment of covered health care expenses that is submitted to an insurer on the insurer’s standard claim form using the most current published procedural codes, with all the required fields completed with correct and complete information in accordance with the insurer’s published filing requirements.

(b) “Electronic claim” means the transmission of data for purposes of payment of covered health care services in an electronic data format specified by the insurer and, if covered by the Health Insurance Portability and Accountability Act (HIPAA), is in such form and substance as to be in compliance with such act.

III. Any initial clean claim submission not paid within the time periods specified in [paragraph I] subparagraph I(a) shall be deemed overdue. [When a claim is overdue, the health care provider may notify the insurer in writing of the insurer’s noncompliance with this section. If the insurer fails to pay the claim within 10 days of receiving the notice, then] In that case:

(a) The insurer shall pay the health care provider or the insured person the amount of the overdue claim [shall include] plus an interest payment of 1.5 percent per month beginning from the date the payment was due; and

(b) The health care provider may recover from the insurer, upon a judicial finding of bad faith, reasonable attorney’s fees for advising and representing a health care provider in a successful action against an insurer for payment of the claim.

IV. Exceptions to the requirements of this section are as follows:

(a) No insurer shall be in violation of this section for a claim submitted by a health care provider if:

(1) Failure to comply is caused by a directive from a court or a federal or state agency;

(2) The insurer is in liquidation or rehabilitation or is operating in compliance with a court-ordered plan of rehabilitation; or

(3) The insurer’s compliance is rendered impossible due to matters beyond the insurer’s control which are not caused by such insurer.

(b) No insurer shall be in violation of this section for any claim submitted more than 90 days after the service was rendered.

(c) No insurer shall be in violation of this section while the claim is pending due to a fraud investigation that has been reported to a state or federal agency, or an internal or external review process.

V. The commissioner may assess an administrative fine against any insurer or may suspend or revoke the license or certificate of authority of any insurer after determining that the insurer has established a pattern of overdue payments and that the contemplated enforcement action would not promote the deterioration of the financial condition of an at-risk insurer. Such fine shall be up to $5,000 per violation, not to exceed $100,000. Nothing in this paragraph shall be construed to alter the commissioner’s authority to investigate or take action, including, but not limited to, action pursuant to RSA 415:20, in response to individual instances of noncompliance.

162:2 Group Insurance; Prompt Payment. Amend RSA 415:18-k to read as follows:

415:18-k Prompt Payment Required.

I.(a) Each insurer that issues or renews any policy of group or blanket accident or health insurance providing benefits for medical or hospital expenses for its insured persons shall pay for services rendered by New Hampshire health care providers within [45] 30 calendar days upon receipt of a clean [written] non-electronic claim or 15 calendar days upon receipt of a clean electronic claim.

(b) [If] When the insurer is denying or pending the claim, the insurer shall have 15 calendar days upon receipt of [the] an electronic claim or 30 days upon receipt of a non-electronic claim to notify the health care provider or certificate holder of the reason for denying or pending the claim and what, if any, additional information is required to [process] adjudicate the claim. Upon the insurer’s receipt of the requested additional information, the insurer shall adjudicate the claim within 45 calendar days. If the required notice is not provided, the claim shall be treated as a clean claim and shall be adjudicated pursuant to subparagraph (a).

(c) Payment of a claim shall be considered to be made on the date a check was issued or electronically transferred. The insurer shall mail checks no later than 5 business days after the date a check was issued. Failure to mail a check within 5 business days shall constitute a violation subject to enforcement under RSA 415:20.

(d) The insurer’s failure to comply with the time limits in this section shall not have the effect of requiring coverage for an otherwise non-covered claim. This section shall only apply to payments made on a claims basis and shall not apply to capitation or other forms of periodic payment.

II. In this section:

(a) “Clean claim” means a claim for payment of covered health care expenses that is submitted to an insurer on the insurer’s standard claim form using the most current published procedural codes, with all the required fields completed with correct and complete information in accordance with the insurer’s published filing requirements.

(b) “Electronic claim” means the transmission of data for purposes of payment of covered health care services in an electronic data format specified by the insurer and, if covered by the Health Insurance Portability and Accountability Act (HIPAA), is in such form and substance as to be in compliance with such act.

III. Any initial clean claim submission not paid within the time periods specified in [paragraph I] subparagraph I(a) shall be deemed overdue. [When a claim is overdue, the health care provider may notify the insurer in writing of the insurer’s noncompliance with this section. If the insurer fails to pay the claim within 10 days of receiving the notice, then] In that case:

(a) The insurer shall pay the health care provider or the insured person the amount of the overdue claim [shall include] plus an interest payment of 1.5 percent per month beginning from the date the payment was due; and

(b) The health care provider may recover from the insurer, upon a judicial finding of bad faith, reasonable attorney’s fees for advising and representing a health care provider in a successful action against an insurer for payment of the claim.

IV. Exceptions to the requirements of this section are as follows:

(a) No insurer shall be in violation of this section for a claim submitted by a health care provider if:

(1) Failure to comply is caused by a directive from a court or a federal or state agency;

(2) The insurer is in liquidation or rehabilitation or is operating in compliance with a court-ordered plan of rehabilitation; or

(3) The insurer’s compliance is rendered impossible due to matters beyond the insurer’s control which are not caused by such insurer.

(b) No insurer shall be in violation of this section for any claim submitted more than 90 days after the service was rendered.

(c) No insurer shall be in violation of this section while the claim is pending due to a fraud investigation that has been reported to a state or federal agency, or an internal or external review process.

V. The commissioner may assess an administrative fine against any insurer or may suspend or revoke the license or certificate of authority of any insurer after determining that the insurer has established a pattern of overdue payments and that the contemplated enforcement action would not promote the deterioration of the financial condition of an at-risk insurer. Such fine shall be up to $5,000 per violation, not to exceed $100,000. Nothing in this paragraph shall be construed to alter the commissioner’s authority to investigate or take action, including, but not limited to, action pursuant to RSA 415:20, in response to individual instances of noncompliance.

162:3 Health Service Corporations; Prompt Payment. Amend RSA 420-A:17-d to read as follows:

420-A:17-d Prompt Payment Required.

I.(a) Every health service corporation, and every other similar corporation licensed under the laws of another state that issues or renews any policy of individual or group blanket accident or health insurance providing benefits for medical or hospital expenses for its insured persons shall pay for services rendered by New Hampshire health care providers within [45] 30 calendar days upon receipt of a clean [written] non-electronic claim or 15 calendar days upon receipt of a clean electronic claim.

(b) [If] When the health service corporation is denying or pending the claim, the corporation shall have 15 calendar days upon receipt of [the] an electronic claim or 30 days upon receipt of a non-electronic claim to notify the health care provider or subscriber of the reason for denying or pending the claim and what, if any, additional information is required to [process] adjudicate the claim. Upon the health service corporation’s receipt of the requested additional information, the health service corporation shall adjudicate the claim within 45 calendar days. If the required notice is not provided, the claim shall be treated as a clean claim and shall be adjudicated pursuant to subparagraph (a).

(c) Payment of a claim shall be considered to be made on the date a check was issued or electronically transferred. The health services corporation shall mail checks no later than 5 business days after the date a check was issued. Failure to mail a check within 5 business days shall constitute a violation subject to enforcement under RSA 415:20.

(d) The corporation’s failure to comply with the time limits in this section shall not have the effect of requiring coverage for an otherwise non-covered claim. This section shall only apply to payments made on a claims basis and shall not apply to capitation or other forms of periodic payment.

II. In this section:

(a) “Clean claim” means a claim for payment of covered health care expenses that is submitted to a health service corporation on the corporation’s standard claim form using the most current published procedural codes, with all the required fields completed with correct and complete information in accordance with the corporation’s published filing requirements.

(b) “Electronic claim” means the transmission of data for purposes of payment of covered health care services in an electronic data format specified by the corporation and, if covered by the Health Insurance Portability and Accountability Act (HIPAA), is in such form and substance as to be incompliance with such act.

III. Any initial clean claim submission not paid within the time periods specified in [paragraph I] subparagraph I(a) shall be deemed overdue. [When a claim is overdue, the health care provider may notify the health service corporation in writing of the health service corporation’s noncompliance with this section. If the health service corporation fails to pay the claim within 10 days of receiving the notice, then] In that case:

(a) The health service corporation shall pay the health care provider or the insured person the amount of the overdue claim [shall include] plus an interest payment of 1.5 percent per month beginning from the date the payment was due; and

(b) The health care provider may recover from the health service corporation, upon a judicial finding of bad faith, reasonable attorney’s fees for advising and representing a health care provider in a successful action against an health service corporation for payment of the claim.

IV. Exceptions to the requirements of this section are as follows:

(a) No health service corporation shall be in violation of this section for a claim submitted by a health care provider if:

(1) Failure to comply is caused by a directive from a court or a federal or state agency;

(2) The corporation is in liquidation or rehabilitation or is operating in compliance with a court-ordered plan of rehabilitation; or

(3) The corporation’s compliance is rendered impossible due to matters beyond the corporation’s control which are not caused by such corporation.

(b) No health service corporation shall be in violation of this section for any claim submitted more than 90 days after the service was rendered.

(c) No health service corporation shall be in violation of this section while the claim is pending due to a fraud investigation that has been reported to a state or federal agency, or an internal or external review process.

V. The commissioner may assess an administrative fine against any health service corporation or may suspend or revoke the license or certificate of authority of any health service corporation after determining that the health service corporation has established a pattern of overdue payments and that the contemplated enforcement action would not promote the deterioration of the financial condition of an at-risk insurer. Such fine shall be up to $5,000 per violation, not to exceed $100,000. Nothing in this paragraph shall be construed to alter the commissioner’s authority to investigate or take action, including, but not limited to, action pursuant to RSA 415:20, in response to individual instances of noncompliance.

162:4 Managed Care; Prompt Payment. Amend RSA 420-J:8-a to read as follows:

420-J:8-a Prompt Payment Required.

I.(a) Health carriers issuing health benefit plans subject to this chapter shall pay claims submitted by health care providers for services rendered in New Hampshire to covered persons within [45] 30 calendar days upon receipt of a clean [written] non-electronic claim or 15 calendar days upon receipt of a clean electronic claim.

(b) [If] When the health carrier is denying or pending the claim, the carrier shall have 15 calendar days upon receipt of [the] an electronic claim or 30 days upon receipt of a non-electronic claim to notify the health care provider or covered person of the reason for denying or pending the claim and what, if any, additional information is required to [process] adjudicate the claim. Upon the health carrier’s receipt of the requested additional information, the health carrier shall adjudicate the claim within 45 calendar days. If the required notice is not provided, the claim shall be treated as a clean claim and shall be adjudicated pursuant to subparagraph (a).

(c) Payment of a claim shall be considered to be made on the date a check was issued or electronically transferred. The health carrier shall mail checks no later than 5 business days after the date a check was issued. Failure to mail a check within 5 business days shall constitute a violation subject to enforcement under RSA 415:20.

(d) The health carrier’s failure to comply with the time limits in this section shall not have the effect of requiring coverage for an otherwise non-covered claim. This section shall only apply to payments made on a claims basis and shall not apply to capitation or other forms of periodic payment.

II. In this section:

(a) “Clean claim” means a claim for payment of covered health care expenses that is submitted to a health carrier on the carrier’s standard claim form using the most current published procedural codes, with all the required fields completed with correct and complete information in accordance with the carrier’s published filing requirements.

(b) “Electronic claim” means the transmission of data for purposes of payment of covered health care services in an electronic data format specified by the health carrier and, if covered by the Health Insurance Portability and Accountability Act (HIPAA), is in such form and substance as to be in compliance with such act.

III. Any initial clean claim submission not paid within the time periods specified in [paragraph I] subparagraph I(a) shall be deemed overdue. [When a claim is overdue, the health care provider may notify the health service corporation in writing of the health service corporation’s noncompliance with this section. If the health service corporation fails to pay the claim within 10 days of receiving the notice, then] In that case:

(a) The health carrier shall pay the health care provider or the insured person the amount of the overdue claim [shall include] plus an interest payment of 1.5 percent per month beginning from the date the payment was due; and

(b) The health care provider may recover from the carrier, upon a judicial finding of bad faith, reasonable attorney’s fees for advising and representing a health care provider in a successful action against a carrier for payment of the claim.

IV. Exceptions to the requirements of this section are as follows:

(a) No health carrier shall be in violation of this section for a claim submitted by a health care provider if:

(1) Failure to comply is caused by a directive from a court or a federal or state agency;

(2) The health carrier is in liquidation or rehabilitation or is operating in compliance with a court-ordered plan of rehabilitation; or

(3) The carrier’s compliance is rendered impossible due to matters beyond the carrier’s control which are not caused by such carrier.

(b) No health carrier shall be in violation of this section for any claim submitted more than 90 days after the service was rendered.

(c) No health carrier shall be in violation of this section while the claim is pending due to a fraud investigation that has been reported to a state or federal agency, or an internal or external review determination pursuant to RSA 420-J:5 or RSA 420-J:5-a-e.

V. The commissioner may assess an administrative fine against any health carrier or may suspend or revoke the license or certificate of authority of any health carrier after determining that the health carrier has established a pattern of overdue payments and that the contemplated enforcement action would not promote the deterioration of the financial condition of an at-risk insurer. Such fine shall be up to $5,000 per violation, not to exceed $100,000. Nothing in this paragraph shall be construed to alter the commissioner’s authority to investigate or take action, including, but not limited to, action pursuant to RSA 415:20, in response to individual instances of noncompliance.

162:5 Effective Date. This act shall take effect 90 days after its passage.

(Approved: June 21, 2005)

(Effective Date: September 19, 2005)

Links

SB78 at GenCourtMobile

Action Dates

Date Body Type

Bill Text Revisions

SB78 Revision: 9331 Date: Jan. 21, 2010, midnight

Docket