(a) For covered services rendered to its members, a health insurer shall reimburse any person entitled to reimbursement under the health benefits plan within 30 days after the receipt of a clean claim.
(b) If a health insurer fails to comply with subsection (a) of this section, the health insurer shall pay interest beginning on the 31st day after the receipt of the claim if the claim remains unpaid after 30 days. A formal claim by the person filing the original claim shall not be required.
(c) The interest payable shall be at a monthly rate of:
(1) One and one-half percent from the 31st day through the 60th day;
(2) Two percent from the 61st day through the 120th day; and
(3) Two and one-half percent after the 120th day.
(d) This section shall not apply to claims if the health insurer:
(1) Notifies the person submitting the claim within 30 days after the receipt of the claim that the legitimacy of the claim or the appropriate amount of reimbursement is in dispute;
(2) States, in writing, to the person the specific reasons why the legitimacy of the claim, a portion of the claim, or the appropriate amount of reimbursement is in dispute; and
(3) Pays any undisputed portion of the claim within 30 days of the receipt of the claim.
(e) The health insurer shall process the disputed portion of the claim within 30 days after receipt of all reasonable and necessary documentation.
(f) If a health insurer fails to comply with the requirements of subsection (e) of this section, it shall pay interest at the rates set forth in subsection (c) of this section beginning on the 31st day after the filing of the receipt of the documentation as provided in subsection (e) of this section.
(g) A health insurer shall allow a provider a minimum of 180 days from the date a covered service is rendered or the date of inpatient discharge to submit a claim for reimbursement for the service.
(h) There shall be a rebuttable presumption that a claim has been received by a health insurer:
(1) Within 5 business days from the date the provider or person entitled to reimbursement placed the claim in the United States mail;
(2) Within 24 hours if the claim was submitted by the provider or provider’s agent electronically and was not returned to the provider by a claims clearinghouse or returned to the provider by the insurer if submitted directly to the health insurer; or
(3) On the date recorded by the courier if the claim was delivered by courier.
(i) Each health insurer shall provide a manual or other document that sets forth the claims submission procedures to all contracting providers at the time of contracting and 30 days prior to any changes in the procedure.
(j) A health insurer shall maintain a written or electronic record of the date of receipt of a claim. The person submitting the claim shall be entitled to inspect the record on request and to rely on that record or on any other admissible evidence as proof of the fact of receipt of the claim, including electronic or facsimile confirmation of receipt of a claim.
(k) A health insurer shall not be in violation of this chapter if its failure to pay a claim in accordance with the time periods provided in this chapter is caused:
(1) In material part by the person submitting the claim; or
(2) By impossibility due to matters beyond the health insurer’s reasonable control, such as an act of God, insurrection, strike, fire, or power outages.
(l) This section shall not apply to claims for which payment has been or will be made directly to health care providers pursuant to a negotiated reimbursement arrangement requiring uniform or periodic interim payments to be applied against the health insurer’s obligation on such claims.
(July 23, 2002, D.C. Law 14-176, § 3, 49 DCR 5086.)
This section is referenced in § 31-3131 and § 31-3138.