Section 21.36.495. Prompt payment of health care insurance claims.

   (a) A health care insurer shall pay or deny indemnities under a health care insurance policy, whether or not services were provided by a participating provider, within 30 calendar days after the insurer or a third-party administrator under contract with the insurer receives a clean claim.
   (b) If a health care insurer does not pay or denies a health care insurance claim, the insurer shall give notice to the covered person, or to the provider of the medical care services or supplies if the claim was assigned or if the covered person elected direct payment under AS 21.51.120(a)(2) or AS 21.54.020(a), of the basis for denial or the specific information that is needed for the insurer to adjudicate the claim. The health care insurer shall provide the notice required under this subsection within 30 calendar days after the insurer or third-party administrator under contract with the insurer receives the claim.
   (c) If a health care insurer does not provide the notice as required under (b) of this section, the claim is presumed a clean claim, and interest shall accrue at a rate of 15 percent annually beginning on the day following the day that the notice was due and continues to accrue until the date that the claim is paid.
   (d) If a health care insurer provides the notice required under (b) of this section and requests specific information that is needed to adjudicate the claim, the insurer shall pay the claim not later than 15 calendar days after receipt of the information specified in the notice or within 30 days after receipt of the claim. If a health care insurer does not pay the claim within the time period required under this subsection, the claim is presumed to be a clean claim, interest at a rate of 15 percent accrues, and interest continues to accrue until the date the claim is paid.
   (e) For purposes of (c) and (d) of this section, if only a portion of a claim is covered under the terms of the insurance policy, interest accrues based only on the portion of the claim that is covered.
   (f) For the purposes of this section, a claim is considered paid on the day payment is mailed or transmitted electronically.
   (g) If interest is accrued on a claim under (c) or (d) of this section, a health care insurer may not include the amount of interest accrued in calculating an applicable limit on benefits payable to a covered person or other person claiming payments under the health insurance policy.
   (h) A health care insurer is not required to pay interest due as a result of the application of (c) or (d) of this section if the amount of the interest is $1 or less.
   (i) In this section,
        (1) "clean claim" means a claim that does not have a defect or impropriety, including a lack of any required substantiating documentation, or a particular circumstance requiring special treatment that prevents timely payment of the claim;
        (2) "health care insurer" has the meaning given in AS 21.54.500.

Authorities

21.06.110;21.36.128

Notes

Implemented As

3 AAC 26.040
3 AAC 26.050
3 AAC 26.070
3 AAC 26.110
3 AAC 26.300

References

3 AAC 26.040
3 AAC 26.050
3 AAC 26.070
3 AAC 26.110
3 AAC 26.300
AS 21.06.110 Director's annual report.
AS 21.36.128

History

(Sec. 32 ch 80 SLA 2006)