Print Friendly HOUSE BILL NO. 743 – Health insurance claims, pymt
HOUSE BILL NO. 743
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H0743.....................................................by WAYS AND MEANS
HEALTH INSURANCE CLAIM - PAYMENT - Adds to existing law to provide for the
submission and prompt payment of health care insurance claims; to define
terms; to provide for the timing and method of claim payments; to provide
for provider billing; to provide that insurers are not required to accept
an assignment of payment; to provide for interest payments; and to set
02/20 House intro - 1st rdg - to printing
02/23 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. 743
BY WAYS AND MEANS COMMITTEE
1 AN ACT
2 RELATING TO HEALTH CARE INSURANCE CLAIMS; AMENDING TITLE 41, IDAHO CODE, BY
3 THE ADDITION OF A NEW CHAPTER 56, TITLE 41, IDAHO CODE, TO DEFINE TERMS,
4 TO PROVIDE FOR THE TIMING AND METHOD OF CLAIM PAYMENTS, TO PROVIDE FOR
5 PROVIDER BILLING, TO PROVIDE THAT INSURERS ARE NOT REQUIRED TO ACCEPT AN
6 ASSIGNMENT OF PAYMENT, TO PROVIDE FOR INTEREST PAYMENTS AND TO SET FORTH
7 EXCEPTIONS; PROVIDING AN EFFECTIVE DATE AND PROVIDING FOR APPLICATION.
8 Be It Enacted by the Legislature of the State of Idaho:
9 SECTION 1. That Title 41, Idaho Code, be, and the same is hereby amended
10 by the addition thereto of a NEW CHAPTER, to be known and designated as Chap-
11 ter 56, Title 41, Idaho Code, and to read as follows:
12 CHAPTER 56
13 TIMELY SUBMISSION AND PAYMENT OF CLAIMS
14 41-5601. DEFINITIONS. As used in this chapter:
15 (1) "Beneficiary" means a policyholder, subscriber, member, employer or
16 other person who is eligible for benefits under a contract providing hospital,
17 surgical or medical expense coverage or a managed care organization or other
18 policy or agreement under which a third party payer agrees to reimburse for
19 covered health care services rendered to beneficiaries in accordance with the
20 benefits contract.
21 (2) "Claim" means an electronically submitted claim from or on behalf of
22 a provider.
23 (3) "Date of payment" means the date the payment is sent by the insurer
24 to the provider.
25 (4) "Insurer" means an authorized insurer, as defined in section 41-110,
26 Idaho Code, that issues health insurance policies to any person within this
28 (5) "Provider" means a physician licensed to practice medicine pursuant
29 to Idaho law and who is in a contractual relationship to provide health care
30 services with the insurer to whom the claim is submitted.
31 (6) "Receipt of claim" means the date the initial claim or the additional
32 requested information or documentation is actually received, whichever is
33 later, by the insurer.
34 41-5602. TIMING AND METHOD OF CLAIM PAYMENTS. (1) Unless otherwise pro-
35 vided in this chapter, an insurer shall process a claim for payment for health
36 care services rendered by a provider to a beneficiary in accordance with this
38 (2) An insurer shall pay, request additional information, or deny a claim
39 not later than thirty (30) days after receipt of the claim.
40 (3) If an insurer denies the claim or needs additional information to
41 process the claim, the insurer shall notify the provider and the beneficiary
1 electronically or in writing. The notice shall state why the insurer denied
2 the claim. If the claim was denied because more information is required to
3 process the claim, the notice shall identify the additional information or
4 supporting documentation that is needed to evaluate the claim for processing.
5 (4) Insurers and providers shall, in connection with all claims, use the
6 current procedural terminology (CPT) code in effect, as published by the Amer-
7 ican medical association, the international classification of disease (ICD)
8 code in effect, as published by the United States department of health and
9 human services, or the healthcare common procedure coding system (HCPCS) code
10 in effect, as published by the United States centers for medicaid and medicare
11 services (CMMS).
12 (5) The provisions of this chapter shall apply only to claims submitted
13 electronically to the insurer.
14 41-5603. PROVIDER BILLING. (1) The provider shall not send a bill to a
15 beneficiary until the time period for payment of a clean claim by the insurer,
16 as set forth in this section, has expired. The provider shall be permitted to
17 send a bill to the beneficiary for payment of any applicable copayment, coin-
18 surance or deductible prior to the expiration of the time period for payment
19 of a clean claim as set forth in this chapter.
20 (2) The provider may send an informational statement to the beneficiary
21 setting forth the charges for the services rendered. Any such statement shall
22 include language, in boldface type with a font size of not less than eighteen
23 (18), informing the beneficiary that the provider has submitted the claim to
24 the beneficiary's insurer for payment and that the beneficiary is not required
25 to submit payment, except for any applicable copayment, coinsurance or deduct-
26 ible, to the provider until the insurer has met the requirements of this chap-
28 (3) A provider shall be required to submit any claim for delivery of
29 health care services under a health benefit plan to an insurer for payment
30 within thirty (30) business days of the date on which service was delivered to
31 an enrollee or a claim was incurred, or pursuant to the contractual terms
32 agreed to between the insurer and the provider, if different. The provider
33 shall submit to the insurer within ten (10) business days after being
34 requested to do so, any additional written itemization, document or other
35 information required by the insurer to justify the claim.
36 (4) If a provider believes that additional time is needed to submit a
37 claim, the insurer must receive written notice requesting additional time
38 within thirty (30) business days of the date on which service was delivered.
39 Upon receipt, the insurer shall provide thirty (30) additional business days
40 for the provider to submit the claim. If after the additional thirty (30)
41 business day period the provider has not submitted the claim along with any
42 required justification, the insurer is not obligated to provide any payment to
43 the provider for that claim.
44 (5) (a) If a provider fails to submit a claim within thirty (30) business
45 days from the date of service and has not requested additional time pursu-
46 ant to subsection (4) of this section, the insurer may deduct one-tenth
47 (1/10) of the total cost of the claim from the payment to the provider
48 for every business day that the provider fails to submit the claim after
49 the initial thirty (30) business day period. After forty (40) business
50 days from the date of service, the insurer is not obligated to provide any
51 payment to the provider.
52 (b) In addition to the provisions of subsection (1) of this section, if a
53 provider has failed to submit a claim within thirty (30) business days
54 from the date of service, then the provisions of this chapter do not apply
1 to that claim.
2 (6) In each instance in which a provider files a duplicate or
3 unprocessible claim, the insurer shall assess the provider five dollars
4 ($5.00). This assessment may be offset against any amount owed to the pro-
5 vider, if any.
6 (7) An insurer may remove a provider from its network if the provider
7 establishes a pattern of failure to submit claims in a timely manner as
8 required by this section. For the purposes of this subsection, a "pattern"
9 shall consist of ten (10) or more documented failures in one (1) calendar
10 year. The insurer shall maintain documentation justifying any removals based
11 upon these failures for purposes of review by the department.
12 (8) A provider is prohibited from billing a patient for any expenses not
13 recovered from an insurer where the insurer is relieved of responsibility for
14 payment or is permitted to take deductions from any amount owed to the pro-
15 vider pursuant to this section.
16 41-5604. ASSIGNMENT. Nothing in this chapter requires an insurer to
17 accept an assignment of payment by the beneficiary to a provider.
18 41-5605. INTEREST PAYMENTS. An insurer that fails to pay, request addi-
19 tional information or documentation, or denies a claim to a provider within
20 the time periods established in this chapter shall pay interest at the con-
21 tract statutory rate pursuant to section 28-22-104, Idaho Code, on the unpaid
22 amount of a claim that is determined to be due and owing. The interest shall
23 accrue from the date payment was due, pursuant to the provisions of this chap-
24 ter, until the claim is paid. Payment of any interest amount of less than five
25 dollars ($5.00) shall not be required.
26 41-5606. EXCEPTIONS. (1) The time periods set forth in this chapter shall
27 not apply to claims for which there is evidence of fraud or misrepresentation
28 by a provider or beneficiary, or to instances where the insurer has not been
29 granted reasonable access to the information under the provider's control.
30 (2) An insurer is not required to comply with the time periods set forth
31 in this chapter if the failure to comply is due to an act of God, bankruptcy,
32 an act of a governmental authority responding to an act of God or emergency,
33 or the result of a strike, walkout or other labor dispute, act of terrorism or
34 during a declaration of war.
35 SECTION 2. This act shall be in full force and effect on and after July
36 1, 2005, and shall apply to those claims with a date of service by a provider
37 on and after July 1, 2005.
STATEMENT OF PURPOSE
The proposed bill imposes upon health care insurers a specific
timetable for prompt payment of health care professionals and
providers. It also imposes upon health care professionals and
providers requirements for prompt submission of claims for
payment as a precondition of prompt payment by the insurer.
The proposed legislation will have no fiscal impact upon the
Name: Charles Lempesis
Health Insurance Association of America
Phone: (208) 661-3093
STATEMENT OF PURPOSE/FISCAL NOTE H 743