SECOND REGULAR SESSION

HOUSE BILL NO. 1245

90TH GENERAL ASSEMBLY


INTRODUCED BY REPRESENTATIVE WRIGHT.

Pre-filed December 21, 1999, and 1000 copies ordered printed.

ANNE C. WALKER, Chief Clerk

2656L.01I


AN ACT

To repeal section 376.383, RSMo Supp. 1999, relating to health care benefits and providers, and to enact in lieu thereof two new sections relating to the same subject, with a penalty provision.




Be it enacted by the General Assembly of the state of Missouri, as follows:

Section A. Section 376.383, RSMo Supp. 1999, is repealed and two new sections enacted in lieu thereof, to be known as sections 376.383 and 431.200, to read as follows:

376.383. 1. To the extent consistent with the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001, et seq., this section shall apply to any health insurer as defined in section 376.806, any nonprofit health service plan and any health maintenance organization.

2. Within forty-five days after receipt of a claim for reimbursement from a person entitled to reimbursement, a health insurer, nonprofit health service plan or health maintenance organization shall pay the claim in accordance with this section or send to the person entitled to reimbursement and the enrollee or insured a notice of receipt and status of the claim that states:

(1) That the insurer, nonprofit health service plan or health maintenance organization refuses to reimburse all or part of the claim and the reason for the refusal; or

(2) That additional information is necessary to determine if all or part of the claim will be reimbursed and what specific additional information is necessary.



A notice which indicates a refusal to reimburse all or part of a claim and the reason for the refusal shall be considered a final determination of an enrollee or insured's health care benefits in the absence of the filing of an appeal pursuant to subsection 4 of this section.

[3.] If an insurer, nonprofit health service plan or health maintenance organization fails to comply with subsection [2 of this section], the insurer, nonprofit health service plan or health maintenance organization shall pay interest on the amount of the claim that remains unpaid forty-five days after the claim is filed at the monthly rate of one percent. The interest paid pursuant to this subsection shall be included in any late reimbursement without the necessity for the person that filed the original claim to make an additional claim for that interest.

[4.] 3. Within ten days after the day on which all additional information is received by an insurer, nonprofit health service plan or health maintenance organization, it shall pay the claim in accordance with this section or send a written notice to the person entitled to reimbursement and the enrollee or insured that:

(1) States refusal to reimburse the claim or any part of the claim; and

(2) Specifies each reason for denial.



A notice which indicates a refusal to reimburse all or part of a claim and specifies each reason for denial shall be considered a final determination of an enrollee or insured's health care benefits in the absence of the filing of an appeal pursuant to subsection 4 of this section. An insurer, nonprofit health service plan or health maintenance organization that fails to comply with this subsection shall pay interest on any amount of the claim that remains unpaid at the monthly rate of one percent.

4. Within forty-five days after the day on which an insurer, nonprofit health service plan or health maintenance organization receives from an enrollee or insured an appeal, pursuant to the terms of the enrollee's or insured's coverage, of a refusal to reimburse any claim or any part of a claim, it shall pay the claim in accordance with this section or send a written notice to the person entitled to reimbursement and the enrollee or insured that: (1) States refusal to reimburse the claim or any part of the claim; and

(2) Specifies each reason for denial.



An insurer, nonprofit health service plan or health maintenance organization that fails to comply with this subsection shall pay interest on any amount of the claim that remains unpaid at the monthly rate of one percent.

5. A provider who is paid interest [under] pursuant to this section shall pay the proportionate amount of said interest to the enrollee or insured to the extent and for the time period that the enrollee or insured had paid for the services and for which reimbursement was due to the insured or enrollee.

[6. This section shall become effective April 1, 1999.]

431.200. 1. As used in this section, the following terms mean:

(1) "Health care benefits", any type of health care coverage which is responsible for paying for services rendered an individual by a health care provider, including, but not limited to insurance or assistance from the state or federal government;

(2) "Health care provider", any physician, dentist, clinical psychologist, pharmacist, optometrist, podiatrist, registered nurse, physician's assistant, chiropractor, physical therapist, nurse anesthetist, anesthetist, emergency medical technician, hospital, nursing home, extended care facility, but not a nursing service, facility or individual which relies upon treatment by spiritual means alone in accordance with the creed or tenets of a church or religious denomination;

(3) "Valid claim", a request by an individual who has received services from a health care provider or a request on behalf of such an individual made by such individual's health care provider for an extension of health care benefits.

2. No health care provider shall charge any late fee or interest on the unpaid balance of an account of an individual who has received services from such health care provider and who has submitted a valid claim for health care benefits until thirty days following the final determination of such individual's total health care benefits made pursuant to section 376.383, RSMo. Any health care provider violating this section is guilty of a class A misdemeanor.



Missouri House of Representatives