0274-hb 1240

CHAPTER 274

HB 1240 - FINAL VERSION

AN ACT requiring the department of health and human services and insurers to make prompt payments.

SPONSORS: Rep. Crosby, Merr 20

This bill requires the department of health and human services to pay its dental and other health care providers for services rendered to medicaid recipients promptly.

This bill also requires insurers offering health benefit plans to pay health care providers in a timely manner.

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Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

AN ACT requiring the department of health and human services and insurers to make prompt payments.

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

274:1 New Section; Prompt Payment Required. Amend RSA 126-A by inserting after section 12 the following new section:

126-A:12-a Prompt Payment Required. The department shall pay health care providers, including dental providers, within 45 days of receipt of a clean claim for services rendered to medicaid recipients. For the purposes of this section "clean claim" means a claim for payment of covered health care expenses that is submitted to the department on the department'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 department's published filing requirements.

274:2 New Section; Prompt Payment Required. Amend RSA 415 by inserting after section 6-g the following new section:

I. 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 calendar days upon receipt of a clean written claim or 15 calendar days upon receipt of a clean electronic claim. If the insurer is denying or pending the claim, the insurer shall have 15 calendar days upon receipt of the 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 the claim. 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.

(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.

III. Any claim not paid within the time periods specified in paragraph I 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:

(a) The amount of the overdue claim shall include 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.

(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.

274:3 New Section; Prompt Payment Required. Amend RSA 415 by inserting after section 18-j the following new section:

I. 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 calendar days upon receipt of a clean written claim or 15 calendar days upon receipt of a clean electronic claim. If the insurer is denying or pending the claim, the insurer shall have 15 calendar days upon receipt of the 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 the claim. 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.

(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.

(a) The amount of the overdue claim shall include an interest payment of 1.5 percent per month beginning from the date the payment was due; and

(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.

274:4 New Section; Prompt Payment Required. Amend RSA 420-A by inserting after section 17-c the following new section:

I. 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 calendar days upon receipt of a clean written claim or 15 calendar days upon receipt of a clean electronic claim. If the health service corporation is denying or pending the claim, the corporation shall have 15 calendar days upon receipt of the 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 the claim. 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.

(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.

III. Any claim not paid within the time periods specified in paragraph I 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:

(a) The amount of the overdue claim shall include 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.

(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.

274:5 New Section; Prompt Payment Required. Amend RSA 420-J by inserting after section 8 the following new section:

I. 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 calendar days upon receipt of a clean written claim or 15 calendar days upon receipt of a clean electronic claim. If the health carrier is denying or pending the claim, the carrier shall have 15 calendar days upon receipt of the 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 the claim. 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.

(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.

III. Any claim not paid within the time periods specified in paragraph I shall be deemed overdue. When a claim is overdue, the health care provider may notify the health carrier in writing of the carrier's noncompliance with this section. If the health carrier fails to pay the claim within 10 days of receiving the notice, then:

(a) The amount of the overdue claim shall include 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.

(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.