HB 1498 -- Health Insurance Claims Reimbursements

Sponsor:  Jones (89)

This bill changes the laws regarding the requirements for
reimbursing health insurance claims.  In its main provisions, the
bill:

(1)  Requires health insurance carriers, including third-party
contractors, to send an electronic acknowledgment of the date of
receipt within two working days after an electronically filed
health care claim is received;

(2)  Increases the length of time, from within 10 working days to
within 15 days, that a health insurance carrier or a third-party
contractor has to send an electronic notice of the status of a
health care claim that notifies the claimant whether the claim
has any reason which will prevent timely payment or if more
information is required.  If the claim is properly filed, the
carrier must pay or deny the claim;

(3)  Adds a penalty equal to one-tenth of the total claim amount
per day on unpaid claims if a carrier has not reimbursed a
claimant within 45 processing days of receiving the claim;

(4)  Increases the amount at which a carrier can combine interest
and payments on unpaid claims from $5 to $100, except for claims
that were properly denied prior to the forty-fifth processing
day;

(5)  Removes the current penalty imposed on carriers that do not
take any action within 40 processing days including notification,
payment, denial, or suspension on received claims;

(6)  Specifies that a claim for which a carrier has not
communicated a specific reason for the denial of reimbursement
cannot be considered denied;

(7)  Changes the procedures a carrier must follow when requesting
additional information to process a claim;

(8)  Prohibits a carrier from requesting a refund or offset
against a claim that was paid more than 12 months prior, except
in cases of fraud or misrepresentation by the provider; and

(9)  Requires, beginning January 1, 2011, a carrier responding to
a patient financial responsibility inquiry utilizing specified
federal electronic eligibility response transaction code sets to
include all six eligibility or benefit information codes.  The
Department of Insurance, Financial Institutions and Professional
Registration must develop a set of best practices to be used by
carriers and providers to standardize the electronic data
exchange.

Missouri House of Representatives
95th General Assembly, 2nd Regular Session
Last Updated September 14, 2010 at 3:11 pm