CODING: Words stricken are deletions; words underlined are additions.
SENATE AMENDMENT
Bill No. CS for CS for SB 362
Amendment No. ___ Barcode 281204
CHAMBER ACTION
Senate House
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11 Senator Saunders moved the following amendment:
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13 Senate Amendment
14 On page 5, line 10, through
15 page 6, line 19, delete those lines
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17 and insert:
18 (2) As used in this section, the term "claim" for a
19 noninstitutional provider means a paper or electronic billing
20 instrument submitted to the insurer's designated location
21 which consists of the HCFA 1500 data set, or its successor,
22 which has all mandatory entries for a physician licensed under
23 chapter 458, chapter 459, chapter 460, or chapter 461 or other
24 appropriate billing instrument that has all mandatory entries
25 for any other noninstitutional provider. For institutional
26 providers, "claim" means a paper or electronic billing
27 instrument submitted to the insurer's designated location
28 which consists of the UB-92 data set or its successor having
29 all mandatory entries. Health insurers shall reimburse all
30 claims or any portion of any claim from an insured or an
31 insured's assignees, for payment under a health insurance
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SENATE AMENDMENT
Bill No. CS for CS for SB 362
Amendment No. ___ Barcode 281204
1 policy, within 45 days after receipt of the claim by the
2 health insurer. If a claim or a portion of a claim is
3 contested by the health insurer, the insured or the insured's
4 assignees shall be notified, in writing, that the claim is
5 contested or denied, within 45 days after receipt of the claim
6 by the health insurer. The notice that a claim is contested
7 shall identify the contested portion of the claim and the
8 reasons for contesting the claim.
9 (3) All claims for payment, whether electronic or
10 nonelectronic:
11 (a) Are considered received on the date the claim is
12 received by the insurer at its designated claims receipt
13 location.
14 (b) Must not duplicate a claim previously submitted
15 unless it is determined that the original claim was not
16 received or is otherwise lost. A health insurer, upon receipt
17 of the additional information requested from the insured or
18 the insured's assignees shall pay or deny the contested claim
19 or portion of the contested claim, within 60 days.
20 (4)(a) For an electronically submitted claim, a health
21 insurer shall, within 24 hours after the beginning of the next
22 business day after receipt of the claim, provide electronic
23 acknowledgement of the receipt of the claim to the electronic
24 source submitting the claim.
25 (b) For an electronically submitted claim, a health
26 insurer shall, within 20 days after receipt of the claim, pay
27 the claim or notify a provider or designee if a claim is
28 denied or contested. Notice of the insurer's action on the
29 claim and payment of the claim is considered to be made on the
30 date the notice or payment is mailed or electronically
31 transferred.
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SENATE AMENDMENT
Bill No. CS for CS for SB 362
Amendment No. ___ Barcode 281204
1 (c)1. Notification of the health insurer's
2 determination of a contested claim must be accompanied by an
3 itemized list of additional information or documents the
4 insurer can reasonably determine are necessary to process the
5 claim.
6 2. A provider must submit the additional information
7 or documentation, as specified on the itemized list, within 35
8 days after receipt of the notification. Failure of a provider
9 to submit by mail or electronically the additional information
10 or documentation requested within 35 days after receipt of the
11 notification may result in denial of the claim.
12 3. A health insurer may not make more than one request
13 for documents under this paragraph in connection with a claim
14 unless the provider fails to submit all of the requested
15 documents to process the claim or the documents submitted by
16 the provider raise new, additional issues not included in the
17 original written itemization, in which case the health insurer
18 may provide the provider with one additional opportunity to
19 submit the additional documents needed to process the claim.
20 In no case may the health insurer request duplicate documents.
21 (d) For purposes of this subsection, electronic means
22 of transmission of claims, notices, documents, forms, and
23 payment shall be used to the greatest extent possible by the
24 health insurer and the provider.
25 (e) A claim must be paid or denied within 90 days
26 after receipt of the claim. Failure to pay or deny a claim
27 within 120 days after receipt of the claim creates an
28 uncontestable obligation to pay the claim. An insurer shall
29 pay or deny any claim no later than 120 days after receiving
30 the claim.
31 (5)(a) For all nonelectronically submitted claims, a
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SENATE AMENDMENT
Bill No. CS for CS for SB 362
Amendment No. ___ Barcode 281204
1 health insurer shall, effective November 1, 2003, provide to
2 the provider acknowledgement of receipt of the claim within 15
3 days after receipt of the claim or provide the provider,
4 within 15 days after receipt, with electronic access to the
5 status of a submitted claim.
6 (b) For all nonelectronically submitted claims, a
7 health insurer shall, within 40 days after receipt of the
8 claim, pay the claim or notify a provider or designee if a
9 claim is denied or contested. Notice of the insurer's action
10 on the claim and payment of the claim are considered to be
11 made on the date the notice or payment was mailed or
12 electronically transferred.
13 (c)1. Notification of the health insurer's
14 determination of a contested claim must be accompanied by an
15 itemized list of additional information or documents the
16 insurer can reasonably determine are necessary to process the
17 claim.
18 2. A provider must submit the additional information
19 or documentation, as specified on the itemized list, within 35
20 days after receipt of the notification. Failure of a provider
21 to submit by mail or electronically the additional information
22 or documentation requested within 35 days after receipt of the
23 notification may result in denial of the claim.
24 3. A health insurer may not make more than one request
25 for documents under this paragraph in connection with a claim
26 unless the provider fails to submit all of the requested
27 documents to process the claim or the documents submitted by
28 the provider raise new, additional issues not included in the
29 original written itemization, in which case the health insurer
30 may provide the provider with one additional opportunity to
31 submit the additional documents needed to process the claim.
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SENATE AMENDMENT
Bill No. CS for CS for SB 362
Amendment No. ___ Barcode 281204
1 In no case may the health insurer request duplicate documents.
2 (d) For purposes of this subsection, electronic means
3 of transmission of claims, notices, documents, forms, and
4 payment shall be used to the greatest extent possible by the
5 health insurer and the provider.
6 (e) A claim must be paid or denied within 120 days
7 after receipt of the claim. Failure to pay or deny a claim
8 within 140 days after receipt of the claim creates an
9 uncontestable obligation to pay the claim. Payment shall be
10 treated as being made on the date a draft or other valid
11 instrument which is equivalent to payment was placed in the
12 United States mail in a properly addressed, postpaid envelope
13 or, if not so posted, on the date of delivery.
14 (6) Payment of a claim is considered made on the date
15 the payment is mailed or electronically transferred. An
16 overdue payment of a claim bears simple interest of 12 percent
17 per year. Interest on an overdue payment for a claim or for
18 any portion of a claim begins to accrue when the claim should
19 have been paid, denied, or contested. The interest is payable
20 with the payment of the claim. All overdue payments shall bear
21 simple interest at the rate of 10 percent per year.
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