Bill Text: CA SB781 | 2015-2016 | Regular Session | Introduced
Bill Title: Health insurance: claims.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Failed) 2016-02-01 - Returned to Secretary of Senate pursuant to Joint Rule 56. [SB781 Detail]
Download: California-2015-SB781-Introduced.html
BILL NUMBER: SB 781 INTRODUCED
BILL TEXT
INTRODUCED BY Senator Allen
FEBRUARY 27, 2015
An act to amend Section 10123.147 of the Insurance Code, relating
to insurance.
LEGISLATIVE COUNSEL'S DIGEST
SB 781, as introduced, Allen. Health insurance: claims.
Exiting law requires insurers issuing group or individual policies
of health insurance that covers hospital, medical, or surgical
expenses to reimburse each complete claim, as specified, as soon as
practical but no later than 30 working days after receipt of the
complete claim. Within 30 working days after receipt of the claim, an
insurer can contest or deny a claim, as specified. An insurer is
required to pay the greater of $15 per year or interest, as
specified, on a claim that is not contested or denied and that has
not been delivered to the claimant within 30 working days after
receipt. Existing law also authorizes the insurer to request
reasonable additional information about the claim, and requires the
service provider making the claim to submit the relevant information
requested to the insurer within 15 working days. Existing law allows
the insurer 30 working days after receipt of the additional
information to reconsider the claim, and requires the insurer to pay
the greater of $15 per year, or interest, as specified, on a claim
that is undergoing reconsideration and that has not been delivered to
the claimant within 30 working days after receipt of the additional
information. Under existing law these requirements are not applicable
to claims to which specified exceptions apply, and the insurer is
required to give written notice to the provider if any of those
exceptions apply within 30 working days of receipt of the claim.
This bill would require an insurer, under those circumstances, to
instead pay to the claimant the greater of $25 per year or the
interest, as specified.
Vote: majority. Appropriation: no. Fiscal committee: no.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 10123.147 of the Insurance Code is amended to
read:
10123.147. (a) Every (1)
An insurer issuing
that issues a group or individual policies
policy of health insurance that covers hospital, medical,
or surgical expenses, including those telehealth services covered by
the insurer as defined in subdivision (a) of Section 2290.5 of the
Business and Professions Code, shall reimburse each complete claim,
or portion thereof, of a claim, whether
in state or out of state, as soon as practical, but no later than 30
working days after receipt of the complete claim by the insurer.
However,
(2) However, an insurer may
contest or deny a claim, or portion thereof,
of the claim, by notifying the claimant, in writing, that the
claim is contested or denied, within 30 working days after receipt of
the complete claim by the insurer. The notice that a claim, or
portion thereof, of a claim, is
contested shall identify the portion of the claim that is contested,
by revenue code, and the specific information needed from the
provider to reconsider the claim. The notice that a claim, or portion
thereof, of a claim, is denied shall
identify the portion of the claim that is denied, by revenue code,
and the specific reasons for the denial, including the factual and
legal basis known at that time by the insurer for each reason. If the
reason is based solely on facts or solely on law, the insurer
is required to shall provide only the
factual or legal basis for its reason to deny the claim. The
(3) The insurer shall provide a
copy of the notice required by this subdivision to each insured who
received services pursuant to the claim that was contested or denied
and to the insured's health care provider that provided the services
at issue. The notice required by this subdivision shall include a
statement advising the provider who submitted the claim on behalf of
the insured or pursuant to a contract for alternative rates of
payment and the insured that either may seek review by the department
of a claim that was contested or denied by the insurer and the
address, Internet Web site address, and telephone number of the unit
within the department that performs this review function. The notice
to the provider may be included on either the explanation of benefits
or remittance advice and shall also contain a statement advising the
provider of its right to enter into the dispute resolution process
described in Section 10123.137. An
(4) An insurer may delay payment
of an uncontested portion of a complete claim for reconsideration of
a contested portion of that claim so long as the insurer pays those
charges specified in subdivision (b).
(b) If a complete claim, or portion thereof,
of the claim, that is neither contested nor denied, is not
reimbursed by delivery to the claimant's address of record within
the 30 working days after receipt, the insurer shall pay the greater
of fifteen twenty-five dollars
($15) ($25) per year or interest at the rate of
10 percent per annum beginning with the first calendar day after the
30-working day period. An insurer shall automatically include the
fifteen twenty-five dollars
($15) ($25) per year or interest due in the
payment made to the claimant, without requiring a request
therefor. request.
(c) (1) For the purposes of this section, a
claim, or portion thereof, of the claim,
is reasonably contested if the insurer has not received the
completed claim. A paper claim from an institutional provider shall
be deemed complete upon submission of a legible emergency department
report and a completed UB 92 or other format adopted by the National
Uniform Billing Committee, and reasonable relevant information
requested by the insurer within 30 working days of receipt of the
claim. An electronic claim from an institutional provider shall be
deemed complete upon submission of an electronic equivalent to the UB
92 or other format adopted by the National Uniform Billing
Committee, and reasonable relevant information requested by the
insurer within 30 working days of receipt of the claim.
However,
(2) However, if the insurer
requests a copy of the emergency department report within the 30
working days after receipt of the electronic claim from the
institutional provider, the insurer may also request additional
reasonable relevant information within 30 working days of receipt of
the emergency department report, at which time the claim shall be
deemed complete. A claim from a professional provider shall be deemed
complete upon submission of a completed HCFA 1500 or its electronic
equivalent or other format adopted by the National Uniform Billing
Committee, and reasonable relevant information requested by the
insurer within 30 working days of receipt of the claim. The provider
shall provide the insurer reasonable relevant information within 15
working days of receipt of a written request that is clear and
specific regarding the information sought. If,
(3) If, as a result of reviewing
the reasonable relevant information, the insurer requires further
information, the insurer shall have an additional 15 working days
after receipt of the reasonable relevant information to request the
further information, notwithstanding any time limit to the contrary
in this section, at which time the claim shall be deemed complete.
(d) This section shall does not
apply to claims a claim about which
there is evidence of fraud and misrepresentation, to eligibility
determinations, or in instances where that
the plan has not been granted reasonable access to information
under the provider's control. An insurer shall specify, in a written
notice to the provider within 30 working days of receipt of the
claim, which, the exceptions, if any, of
these exceptions applies that apply to
a claim.
(e) If a claim or portion thereof of a
claim is contested on the basis that the insurer has not
received information reasonably necessary to determine payer
liability for the claim or portion thereof,
of the claim, then the insurer shall have 30 working days after
receipt of this additional information to complete reconsideration
of the claim. If a claim, or portion thereof,
of a claim, undergoing reconsideration is not reimbursed by
delivery to the claimant's address of record within the 30 working
days after receipt of the additional information, the insurer shall
pay the greater of fifteen twenty-five
dollars ($15) ($25) per year or
interest at the rate of 10 percent per annum beginning with the first
calendar day after the 30-working day period. An insurer shall
automatically include the fifteen twenty-five
dollars ($15) ($25) per year or
interest due in the payment made to the claimant, without requiring a
request therefor. request.
(f) An insurer shall not delay payment on a claim from a physician
and surgeon or other health care provider to
await the submission of a claim from a hospital or other provider,
without citing specific rationale as to why the delay was necessary
and providing a monthly update regarding the status of the claim and
the insurer's actions to resolve the claim, to the provider that
submitted the claim.
(g) An insurer shall not request or require that a provider waive
its rights pursuant to this section.
(h) This section shall apply applies
only to claims for services rendered to a patient who was provided
emergency services and care as defined in Section 1317.1 of the
Health and Safety Code in the United States on or after September 1,
1999.
(i) This section shall not be construed to
does not affect the rights or obligations of any
a person pursuant to Section 10123.13.
(j) This section shall not be construed to
does not affect a written agreement, if any, of a provider to
submit bills within a specified time period.
