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Ohio and Federal Prompt Pay Requirements

Posted Date: June 5th, 2014 |


Prompt Pay Requirements

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.  Contact the Jones Law Group at (614) 545-9998 for more information.

 

 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.

 1.  The time period is not suspended if a third-party payer requests additional supporting documentation after receiving initially requested information.

2       A request for additional supporting documentation that is made outside the thirty (30) day time period and that is based on information received in the initial request regarding a previously unknown pre-existing condition may suspend the 45 day processing time.

  •  A third-party payer has 15 days from receipt to notify a provider when a materially deficient claim is received.

 1. Examples of materially deficient claims include claims with an incorrect patient name or benefit contracts number, a patient that cannot be identified, a claim without a treatment code or a claim without a provider’s identifying number.

2. The 15 day time period and the time spent correcting the deficiencies do not count toward the calculation of time in which a claim must be processed. 

  • A third-party payer may refuse to process a claim submitted by a provider if the provider submits the claim later than 45 days after receiving notice from a different third-party payer or a state or federal program that that payer or program is not responsible for the cost of the health care services, or if the provider does not submit the notice of denial from the different third-party payer or program with the claim.
  • A third-party payer that has a timely filing requirement must process an untimely claim if all the following apply:

1.  The claim was initially submitted to a different third-party payer or state or federal program;

2.  The provider submits the claim to the second payer within 45 days of    receiving notice that the first payer denied the claim; and

3.  The provider submits the notice of denial along with the claim. 

  • When a claim is submitted later than one year after the last date of service for which reimbursement is sought, a third-party payer shall pay or deny the claim not later than 90 days after receipt of the claim or, alternatively, pursuant to the requirements of sections 3901.381 to 3901.388 of the Revised Code. 

Online Complaint Process Instructions for State Prompt Pay Violations 

  • A provider should follow all contract grievance and appeal procedures before filing a complaint with the Department.
  • If the complaint cannot be resolved through normal channels, a healthcare provider may submit a prompt pay complaint to the Ohio Department of Insurance by completing an online complain form. 

 Federal Prompt Pay Requirements 

  • Section 1932(f) of the Social Security Act establishes the timeliness requirements of claims processing that Medicare, Medicaid or self-insured ERISA plans must meet.
  • Third-party payers subject to the federal requirements must:
    1. Pay 90% of clean claims (those requiring no additional documentation) received IN AGGERGATE FROM ALL PROVIDERS within 30 days of receipt.
    2. Pay 99% of all clean claims received IN AGGERGATE FROM ALL PROVIDERS within 90 days of receipt.
    3. Providers that have contracted with a third-party payer for an alternate schedule are excluded form the aggregate calculation. 

Filing Complaints for Violations of Federal Requirements

For Self-funded Plans subject to ERISA, please contact: 

Department of Labor
1885 Dixie Highway, Suite 210
Ft. Wright, KY 41011
(859) 578-4680
(866) 275-7922 Toll-free
www.dol.gov/ebsa

For Medicare Claims, please contact:

Centers for Medicare and Medicaid Region V
233 N. Michigan Ave, Suite 600
Chicago, IL 60601
(312) 353-3620
 www.medicare.gov

For Medicaid Fee-For-Service Claims, please contact:

Ohio Department of Jobs & Family Services
Ombudsman/Technical Assistance Unit
Re: Medicaid
PO Box 1461
Columbus, Ohio 43216-1461
(614) 752-9551
http://jfs.ohio.gov/ohp/index.stm

 

Other useful information posted on the ODI website

Prompt Pay Links



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