376.383. Health care claims for reimbursement, how paid, when--definitions--interest on unpaid claims--effective, when--penalties for unpaid claims, when--fraudulent claims, notification to the depart
Health care claims for reimbursement, how paid,when--definitions--interest on unpaid claims--effective,when--penalties for unpaid claims, when--fraudulent claims,notification to the department, procedure--requests foradditional information, contents.
376.383. 1. For purposes of this section and section 376.384, thefollowing terms shall mean:
(1) "Claimant", any individual, corporation, association, partnership orother legal entity asserting a right to payment arising out of a contract or acontingency or loss covered under a health benefit plan as defined in section376.1350;
(2) "Deny" or "denial", when the health carrier refuses to reimburse allor part of the claim;
(3) "Health carrier", health carrier as defined in section 376.1350,except that health carrier shall not include a workers' compensation carrierproviding benefits to an employee pursuant to chapter 287, RSMo;
(4) "Health care provider", health care provider as defined in section376.1350;
(5) "Health care services", health care services as defined in section376.1350;
(6) "Processing days", number of days the health carrier has the claimin its possession. Processing days shall not include days in which the healthcarrier is waiting for a response to a request for additional information;
(7) "Request for additional information", when the health carrierrequests information from the claimant to determine if all or part of theclaim will be reimbursed;
(8) "Suspends the claim", giving notice to the claimant specifying thereason the claim is not yet paid, including but not limited to grounds aslisted in the contract between the claimant and the health carrier; and
(9) "Third-party contractor", a third party contracted with the healthcarrier to receive or process claims for reimbursement of health careservices.
2. Within ten working days after receipt of a claim by a health carrieror a third-party contractor, a health carrier shall:
(1) Send an acknowledgment of the date of receipt; or
(2) Send notice of the status of the claim that includes a request foradditional information.
If a health carrier pays the claim, subdivisions (1) and (2) shall not apply.
3. Within fifteen days after receipt of additional information by ahealth carrier or a third-party contractor, a health carrier shall pay theclaim or any undisputed part of the claim in accordance with this section orsend a notice of receipt and status of the claim:
(1) That denies all or part of the claim and specifies each reason fordenial; or
(2) That makes a final request for additional information.
4. Within fifteen days after the day on which the health carrier or athird-party contractor receives the additional requested information inresponse to a final request for information, it shall pay the claim or anyundisputed part of the claim or deny or suspend the claim.
5. If the health carrier has not paid the claimant on or before theforty-fifth day from the date of receipt of the claim, the health carriershall pay the claimant one percent interest per month. The interest shall becalculated based upon the unpaid balance of the claim. The interest paidpursuant to this subsection shall be included in any late reimbursementwithout the necessity for the person that filed the original claim to make anadditional claim for that interest. A health carrier may combine interestpayments and make payment once the aggregate amount reaches five dollars.
6. If a health carrier fails to pay, deny or suspend the claim withinforty processing days, and has received, on or after the fortieth day, noticefrom the health care provider that such claim has not been paid, denied orsuspended, the health carrier shall, in addition to monthly interest due, payto the claimant per day an amount of fifty percent of the claim but not toexceed twenty dollars for failure to pay all or part of a claim or interestdue thereon or deny or suspend as required by this section. Such penaltyshall not accrue for more than thirty days unless the claimant provides asecond written or electronic notice on or after the thirty days to the healthcarrier that the claim remains unpaid and that penalties are claimed to be duepursuant to this section. Penalties shall cease if the health carrier pays,denies or suspends the claim. Said penalty shall also cease to accrue on theday after a petition is filed in a court of competent jurisdiction to recoverpayment of said claim. Upon a finding by a court of competent jurisdictionthat the health carrier failed to pay a claim, interest or penalty withoutreasonable cause, the court shall enter judgment for reasonable attorney feesfor services necessary for recovery. Upon a finding that a provider filedsuit without reasonable grounds to recover a claim, the court shall award thehealth carrier reasonable attorney fees necessary to the defense.
7. The department of insurance, financial institutions and professionalregistration shall monitor suspensions and determine whether the healthcarrier acted reasonably.
8. If a health carrier or third-party contractor has reasonable groundsto believe that a fraudulent claim is being made, the health carrier orthird-party contractor shall notify the department of insurance, financialinstitutions and professional registration of the fraudulent claim pursuant tosections 375.991 to 375.994, RSMo.
9. Denial of a claim shall be communicated to the claimant and shallinclude the specific reason why the claim was denied.
10. Requests for additional information shall specify what additionalinformation is necessary to process the claim for payment. Informationrequested shall be reasonable and pertain to the health carrier'sdetermination of liability. The health carrier shall acknowledge receipt ofthe requested additional information to the claimant within five working daysor pay the claim.
(L. 1998 H.B. 1302 § 7, A.L. 2001 H.B. 328 & 88)Effective 1-01-02