Insurance Prompt Pay Requirements

Posted Date: December 11th, 2013 |

In Ohio, there are two separate prompt pay requirements for health insuring Corporations. Medicare, Medicaid or self-insured ERISA plans must comply with federal prompt payment requirements. Otherwise, third-party payers must comply with the state prompt pay requirements.  Failure to comply obligates insurers to pay interest on late payments.

Ohio’s Prompt Pay Law Requires Third-Party Payers to:

  • Inform providers about supporting medical documentation that is routinely required for a particular service.
  • Establish a claim status check system by which providers and beneficiaries may determine the status of a particular claim.
  • Automatically pay interest on claims that are not paid in accordance with the time frames in Ohio’s prompt pay law. The interest rate is eighteen per cent annually.
  • Provide requests for supporting documentation in writing if requested.

Ohio’s Prompt Pay Time Frames

  • Section 3901.381 of the Revised Code establishes the time frames for the processing and payment of claims. The time frames vary depending upon the circumstances.
  • A third-party payer has 30 days to process a claim if no supporting documentation is needed, often referred to as a “clean claim.”
  • If additional information is required, the third-party payer must notify the provider and the patient that supporting information is needed within 30 days of receipt of the claim.
  • A third-party payer has 45 days to process a claim if the third-party payer requests additional supporting documentation. The time period of 45 days is suspended until the third-party payer receives the last piece of information requested in the initial 30 day period.

For more information on Prompt Pay laws and requirements please contact the Jones Law Group at  (614) 545-9998.

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