Which is the process of collecting appropriate reimbursement for services rendered?

Time to File Claims. Providers are required to submit health care claims within 120 days after the date of service for the claims to be valid and enforceable against HMOs and insurers, unless the parties agree to a time period that is more favorable to the provider. (Providers are required to submit claims within 90 days after the date of service for Medicaid managed care plans.)

Promptly Pay Claims. HMOs and insurers are required to pay claims for health care services within 30 days of receipt if the claims are submitted through the internet or by e-mail and within 45 days of receipt if the claims are submitted on paper or by fax, except in cases where the obligation to make payment is not reasonably clear or there is evidence that the bill may be fraudulent.

Obligation To Pay. If the obligation to pay is not reasonably clear, an HMO or insurer shall pay any undisputed portion of the claim and either notify the member or provider, in writing, within 30 calendar days of the receipt of the claim that the health plan is not obligated to pay and the reasons, or request additional information needed to determine liability to pay the claim or make the payment.

Timeframe. Upon receipt of the information requested, or an appeal of a claim for the denied health care services, an HMO or insurer shall comply with the 30 or 45-day requirement for clean claims.

Reconsideration. Participating health care providers may request reconsideration of a claim that is denied solely because it was untimely submitted. If the provider can demonstrate that his or her non-compliance was a result of an unusual occurrence and that he or she has a pattern or practice of timely submitting claims, the HMO or insurer is required to pay such claim, but may reduce the reimbursement due by up to 25% of what the HMO or insurer would have paid had the claim been timely submitted.

Hospital Claims. Within 30 days of receipt of payment of a claim for which payment has been adjusted based on a particular coding to a patient, a hospital has the opportunity to submit the affected claim with medical records supporting the hospital's initial coding of the claim. Upon receipt, the HMO or insurer is required to review such information to ascertain the correct coding for payment and process the claim in accordance with the timeframes set forth above. If the HMO or insurer processes the claim consistent with its initial determination, it is required to provide a statement with the decision explaining why the initial adjustment was appropriate. If the HMO or insurer increases the payment based on the information submitted by the hospital, but fails to do so within the required timeframes, it is required to pay interest on the amount of such increase at the rate set by the commissioner of taxation and finance for corporate taxes, computed from the end of the 45-day period after resubmission of the additional medical record information.

Violation. Each claim or bill processed after the 30 or 45-day time period is a separate violation.

Payment of Interest. For any violation of the prompt payment law, interest is due. Interest is calculated as the greater of: 12% per annum or the rate set by the commissioner of taxation and finance for corporate taxes pursuant to New York Tax Law Section 1096(e)(1). Interest is calculated from the date the claim or health care payment was required to be made. When the amount of interest due is less than two dollars, the HMO or insurer is not required to pay the interest.

File a Prompt Payment Complaint

The Department of Financial Services investigates insurance complaints involving licensed insurance entities. This Department cannot act as your lawyer, give legal advice, recommend, or rate insurers.

Before contacting us regarding an alleged prompt pay violation, please do the following:

• Contact the insurer or HMO to verify that the claim was received.
• Determine the type of coverage. If the patient is covered by a self-funded plan or Medicare, DFS lacks jurisdiction to assist.
• Review your records to ensure the claim has not been paid or denied.
• If the insurer or HMO has requested additional documentation and you have not supplied it, the claim is not delinquent and should not be submitted as a complaint.

You can file a No Fault, Workers Compensation or Prompt Pay Complaint online via the secure DFS Portal.

You will receive immediate confirmation and be assigned a file number.

You will have 30 minutes to process the complaint form. If you do not complete the form within 30 minutes you will be prompted to refresh and the information you have entered before refreshing will be lost.

To get started, visit the DFS portal:

DFS Portal

What process assists the providers in the overall collection of appropriate reimbursement for services rendered?

Which assist provider is best in the overall collection of appropriate?

Which means the provider agrees to accept what the insurance company allows or approves as payment in full for the claim?

Which is an electronic format supported for health care claims transactions?