SS/HB 259 - This act modifies Missouri's prompt pay law as it pertains to the payment of health insurance claims made by a health care provider. The act provides a definition for the term "clean claim." The term "clean claim" is defined as a claim that has no defect, impropriety, lack of any required substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment. Under the proposed act, the definition of health carrier is modified to include self-insured health plans, to the extent allowed by federal law. The act amends the term "processing days" to include the number of days a health carrier's agents, subsidiaries, contractors, subcontractors or third-party contractors have a claim in their possession. The act also amends the definition of "request for additional information" to mean a health carrier's electronic request for additional information from a claimant which specifies all of the information that is needed in order to process the claim for payment. The act also deletes the definition of the term "suspends the claim" and removes the use of the phrase from section 376.383. Under the terms of the act, a health carrier must send an electronic acknowledgment of the date of receipt of an electronically filed claim by a health carrier or a third-party contractor within one working day.
Within 15 days (current law allows 10 working days) after receipt of a filed claim by a health carrier, the health carrier must send an electronic notice of the status of the claim that notifies the claimant:
(1) Whether the claim is a clean claim; or
(2) The claim requires additional information from the claimant.
If the claim is a clean claim, the health carrier must either pay or deny the claim. If the claim requires additional information, the notice shall include a request for additional information.
The act modifies the interest and penalty provision for failing to promptly pay a claim. Under the proposed act, if the health carrier has not paid the claimant on or before the 45th processing day from the date of the receipt of the claim, the health carrier must pay the claimant 1% interest per month and a penalty in an amount equal to one-fifth of the claim per day. The current statutory penalty provision is repealed. That provision required the health carrier to pay the claimant a daily penalty of 50% of the claim, but not to exceed $20, for failure to pay the claim in a timely manner. Under the act, the interest and penalties cease to accrue on the day a petition is filed in court to recover payment on a claim.
If a court determines that a health carrier has failed to pay a claim, interest, or penalty without good cause, the court shall enter judgment for attorney fees. If the court determines that a health care provider has filed suit without reasonable grounds to recover a claim, the court shall award the health carrier reasonable attorney fees related to the defense.
Under the terms of the act, any claim for which the health carrier has not communicated a specific reason for the denial shall not be considered denied under the prompt pay statutes.
Under the terms of the act, requests for additional information shall specify all of the documentation and additional information that is necessary to process all of the claim, or all of the claims on a multi-claim form, as a clean claim for payment. Information requested shall be reasonable and pertain solely to the health carrier's determination of liability.
The prompt pay provision is substantially similar to the one contained in SB 236 (2009)(Section 376.383).
This act also prohibits contracts between health carriers and health care providers from containing provisions that require health care providers to disclose their reimbursement rates with other health carriers. Under the act, such provisions are void and unenforceable. This provision is substantially similar to the one contained in SB 478 (2009)(Section 376.444).
STEPHEN WITTE