Bill Text: CA AB2410 | 2013-2014 | Regular Session | Introduced
Bill Title: Insurance: life and disability insurance.
Sponsorship: Partisan Bill (Democrat 1)
Status: (Introduced - Dead) 2014-03-10 - Referred to Com. on INS. [AB2410 Detail]
Download: California-2013-AB2410-Introduced.html
BILL NUMBER: AB 2410 INTRODUCED
BILL TEXT
INTRODUCED BY Assembly Member Dababneh
FEBRUARY 21, 2014
An act to amend Section 10123.147 of the Insurance Code, relating
to insurance.
LEGISLATIVE COUNSEL'S DIGEST
AB 2410, as introduced, Dababneh. Insurance: life and disability
insurance.
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, and the insurer
can request reasonable additional information about the claim. The
provider is required to submit the relevant information requested to
the insurer within 15 working days. 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.
This bill would instead require insurers to contest or deny a
claim and request reasonable additional information within 45
calendar days after receipt of the claim, and require providers to
submit the requested additional information to the insurer within 21
calendar days. This bill would also require insurers to pay the
greater of $30 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 45 working days after receipt.
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 insurer issuing group or individual policies
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, whether in state or out of state, as soon as practical, but
no later than 30 working 45 calendar
days after receipt of the complete claim by the insurer. However, an
insurer may contest or deny a claim, or portion thereof, by notifying
the claimant, in writing, that the claim is contested or denied,
within 30 working 45 calendar days
after receipt of the complete claim by the insurer. The notice that a
claim, or portion thereof, 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, 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 provide only the factual or legal basis for its reason to
deny the claim. 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 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, that is neither
contested nor denied, is not reimbursed by delivery to the claimant's
address of record within the 30 working 45
calendar days after receipt, the insurer shall pay the greater
of fifteen dollars ($15) thirty dollars ($30)
per year or interest at the rate of 10 percent per annum
beginning with the first calendar day after the 30-working
45-calendar day period. An insurer shall
automatically include the fifteen dollars ($15)
thirty dollars ($30) per year or interest due in the
payment made to the claimant, without requiring a request therefor.
(c) For the purposes of this section, a claim, or portion thereof,
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 45
calendar 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 45 calendar days of receipt of the
claim. However, if the insurer requests a copy of the emergency
department report within the 30 working 45
calendar days after receipt of the electronic claim from the
institutional provider, the insurer may also request additional
reasonable relevant information within 30 working
45 calendar 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 45 calendar days of receipt
of the claim. The provider shall provide the insurer reasonable
relevant information within 15 working 21
calendar days of receipt of a written request that is clear and
specific regarding the information sought. If, as a result of
reviewing the reasonable relevant information, the insurer requires
further information, the insurer shall have an additional 15
working 21 calendar 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 not apply to claims about which there is
evidence of fraud and misrepresentation, to eligibility
determinations, or in instances where 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 45 calendar days of receipt
of the claim, which, if any, of these exceptions applies to a claim.
(e) If a claim or portion thereof is contested on the basis that
the insurer has not received information reasonably necessary to
determine payer liability for the claim or portion thereof, then the
insurer shall have 30 working 45 calendar
days after receipt of this additional information to complete
reconsideration of the claim. If a claim, or portion thereof,
undergoing reconsideration is not reimbursed by delivery to the
claimant's address of record within the 30 working
45 calendar days after receipt of the additional
information, the insurer shall pay the greater of fifteen
dollars ($15) thirty dollars ($30) per year or
interest at the rate of 10 percent per annum beginning with the first
calendar day after the 30-working
45-calendar day period. An insurer shall automatically include
the fifteen dollars ($15) thirty
dollars ($30) per year or interest due in the
payment made to the claimant, without requiring a request therefor.
(f) An insurer shall not delay payment on a claim from a physician
or other 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 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 affect the rights or
obligations of any person pursuant to Section 10123.13.
(j) This section shall not be construed to affect a written
agreement, if any, of a provider to submit bills within a specified
time period.
