Print Friendly HOUSE BILL NO. 705 – Health insurance, payment of claims
HOUSE BILL NO. 705
View Bill Status
View Bill Text
View Statement of Purpose / Fiscal Impact
Text to be added within a bill has been marked with Bold and
Underline. Text to be removed has been marked with
Strikethrough and Italic. How these codes are actually displayed will
vary based on the browser software you are using.
This sentence is marked with bold and underline to show added text.
This sentence is marked with strikethrough and italic, indicating
text to be removed.
HEALTH INSURANCE - CLAIMS PAYMENT - Adds to existing law relating to the
prompt payment of health insurance claims; to define terms; to provide for
the timing and method of claim payments; to provide for provider billing;
to provide for interest payments; and to provide exceptions.
02/16 House intro - 1st rdg - to printing
02/17 Rpt prt - to Bus
]]]] LEGISLATURE OF THE STATE OF IDAHO ]]]]
Fifty-seventh Legislature Second Regular Session - 2004
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 705
BY BUSINESS COMMITTEE
1 AN ACT
2 RELATING TO PROMPT PAYMENT OF HEALTH INSURANCE CLAIMS; AMENDING TITLE 41,
3 IDAHO CODE, BY THE ADDITION OF A NEW CHAPTER 56, TITLE 41, IDAHO CODE, TO
4 DEFINE TERMS, TO PROVIDE FOR THE TIMING AND METHOD OF CLAIM PAYMENTS, TO
5 PROVIDE FOR PROVIDER BILLING, TO PROVIDE FOR INTEREST PAYMENTS AND TO PRO-
6 VIDE EXCEPTIONS; PROVIDING AN EFFECTIVE DATE AND PROVIDING APPLICATION.
7 Be It Enacted by the Legislature of the State of Idaho:
8 SECTION 1. That Title 41, Idaho Code, be, and the same is hereby amended
9 by the addition thereto of a NEW CHAPTER, to be known and designated as Chap-
10 ter 56, Title 41, Idaho Code, and to read as follows:
11 CHAPTER 56
12 PAYMENT OF CLAIMS
13 41-5601. DEFINITIONS. As used in this chapter:
14 (1) "Beneficiary" means a policyholder, subscriber, member, or other per-
15 son who is eligible for benefits under a contract providing hospital, surgi-
16 cal, or medical expense coverage or a managed care organization or other pol-
17 icy or agreement under which a third party payer agrees to reimburse for cov-
18 ered health care services rendered to beneficiaries in accordance with the
19 benefits contract.
20 (2) "Claim" is an electronically submitted claim from or on behalf of a
22 (3) "Date of payment" means the date the payment is sent by the insurer
23 to the provider.
24 (4) "Electronically submitted" means any process of communication that is
25 suitable for the retention, retrieval and reproduction of information by the
26 recipient and which does not directly involve the physical transfer of paper.
27 (5) "Insurer" means an authorized insurer, as defined in section 41-110,
28 Idaho Code, that issues health insurance policies to any person within this
30 (6) "Provider" means a physician licensed to practice medicine pursuant
31 to Idaho law and who is in a contractual relationship to provide health care
32 services with the insurer to whom the claim is submitted.
33 (7) "Receipt of claim" means the date the initial claim or the additional
34 requested information or documentation is actually received, whichever is
35 later, by the insurer.
36 41-5602. TIMING AND METHOD OF CLAIM PAYMENTS. (1) Unless otherwise pro-
37 vided in this chapter, an insurer shall process a claim for payment for health
38 care services rendered by a provider to a beneficiary in accordance with this
40 (2) An insurer shall pay, request additional information, or deny a claim
41 not later than thirty (30) days after receipt of the claim.
1 (3) If an insurer denies the claim or needs additional information to
2 process the claim, the insurer shall notify the provider and the beneficiary
3 electronically or in writing. The notice shall state why the insurer denied
4 the claim. If the claim was denied because more information is required to
5 process the claim, the notice shall identify the additional information or
6 supporting documentation that is needed to evaluate the claim for processing.
7 (4) Insurers and providers shall, in connection with all claims, use the
8 current procedural terminology (CPT) code in effect, as published by the Amer-
9 ican medical association, the international classification of disease (ICD)
10 code in effect, as published by the United States department of health and
11 human services, or the healthcare common procedural coding system (HCPCS) code
12 in effect, as published by the United States centers for medicaid and medicare
13 services (CMMS).
14 (5) The provisions of this chapter shall apply only to electronically
15 submitted claims.
16 41-5603. PROVIDER BILLING. (1) The provider shall be permitted to send a
17 bill to the beneficiary for payment of any applicable copayment, coinsurance
18 or deductible.
19 (2) The provider may send an informational statement to the beneficiary
20 setting forth the charges for the services rendered. Any such statement shall
21 include language, in boldface type with a font size not less than eighteen
22 (18), informing the beneficiary that the provider has submitted the claim to
23 the beneficiary's insurer for payment and that the beneficiary is not required
24 to submit payment, except for any applicable copayment, coinsurance or deduct-
25 ible, to the provider until the insurer has met the requirements of this chap-
27 (3) A provider shall be required to submit any claim for delivery of
28 health care services under a health benefit plan to an insurer for payment
29 pursuant to the contractual terms agreed to between the health carrier and the
30 provider. The provider shall submit to the health carrier within ten (10)
31 business days after receipt of request to do so, any additional written item-
32 ization, document, or other information required by the health carrier to jus-
33 tify the claim.
34 41-5604. INTEREST PAYMENTS. An insurer that fails to pay, request addi-
35 tional information or documentation or deny a claim to a provider within the
36 time periods established in this chapter shall pay interest at the contract
37 statutory rate pursuant to section 28-22-104, Idaho Code, on the unpaid amount
38 of a claim that is determined to be due and owing. The interest shall accrue
39 from the date payment was due, pursuant to the provisions of this chapter,
40 until the claim is paid. Payment of any interest amount of less than five dol-
41 lars ($5.00) shall not be required. Insurers may add any interest due to a
42 future payment to the provider.
43 41-5605. EXCEPTIONS. The time periods set forth in this chapter shall not
44 apply to claims for which there is evidence of fraud, or misrepresentation by
45 a provider or beneficiary, or to instances where the insurer has not been
46 granted reasonable access to the information under the provider's control. An
47 insurer is not required to comply with the time periods set forth in this
48 chapter if the failure to comply is due to an act of God, bankruptcy, an act
49 of a governmental authority responding to an act of God or emergency, or the
50 result of a strike, walkout or other labor dispute, act of terrorism or during
51 a declaration of war.
1 SECTION 2. This act shall be in full force and effect on and after July
2 1, 2005, and shall apply to those claims with a date of service by a provider
3 on and after July 1, 2005.
STATEMENT OF PURPOSE
This legislation requires prompt payment by health insurance
carriers of claims submitted electronically by contracting
It allows contracting physicians to send the patient an
informational statement setting forth the fees for services, but
prohibits the physician from seeking immediate payment except for
applicable coinsurance, deductibles and copayments.
It requires a health insurance carrier to pay the physician the
statutory contract rate of interest for claims not paid within the
proper time frame.
There is no fiscal impact.
Contact: Idaho Association of Health Plans
Steve Tobiason 342-4545
Lyn Darrington 336-1986
STATEMENT OF PURPOSE/FISCAL NOTE H 705