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1999 SESSION

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SB 1176 Health insurance; fair business practices.

Introduced by: Richard L. Saslaw | all patrons    ...    notes | add to my profiles | history

SUMMARY AS PASSED:

Health insurance; fair business practices. Establishes fair business practices standards applicable to the claim reimbursement practices of health insurance carriers, health services plans and HMOs (referred to as “carriers”). The section requires a carrier to (i) pay claims within 40 days of claim receipt, unless the claim is not a clean claim, is disputed in good faith, or otherwise has no obligation to be paid; (ii) contact health care providers within 30 days of receiving reimbursement claims if it desires further claim information or documentation; and (iii) establish reasonable policies giving providers notice of and detailed information concerning the carrier’s required administrative claims processing procedures. The legislation also prohibits retroactive claim denial unless claims are fraudulent, previously paid, or retroactively reviewed within the lesser of 12 months or a period equal to the number of days in which claims must be submitted after a health care service is provided. On and after July 1, 2000, a carrier must notify a provider at least 30 days in advance of any retroactive denial of a claim. The bill also requires that carriers’ provider contracts (and any subsequent amendments) disclose carrier reimbursement fee schedules and policies. The legislation establishes private rights of action for providers who suffer actual damages resulting from carrier violations of the bill’s provisions. Providers are entitled to recover treble damages for any willful violations. The Virginia State Corporation Commission is given regulatory oversight concerning the bill’s provisions. This bill is identical to House Bill 2213.

SUMMARY AS PASSED SENATE:

Health insurance; fair business practices. Establishes fair business practices standards applicable to the claim reimbursement practices of health insurance carriers, health services plans and HMOs (referred to as “carriers”). The section requires carriers to (i) pay claims within 40 days of claim receipt, unless the claim is not a clean claim, is disputed in good faith, or there is otherwise no obligation to pay, (ii) contact health care providers within 30 days of receiving reimbursement claims if they desire further claim information or documentation, and (iii) establish reasonable policies giving providers notice of and detailed information concerning carriers’ required administrative claims processing procedures. The legislation also prohibits retroactive claim denial unless claims are fraudulent, previously paid, or retroactively reviewed within the lesser of 12 months or a period equal to the number of days in which claims must be submitted after a health care service is provided. On and after July 1, 2000, a carrier must notify a provider at least 30 days in advance of any retroactive denial of a claim. The bill also requires that carriers’ provider contracts (and any subsequent amendments) disclose carrier reimbursement fee schedules and policies. The legislation establishes private rights of action for providers who suffer actual damages resulting from carrier violations of the bill’s provisions. Providers are entitled to recover treble damages for any willful violations. The Virginia State Corporation Commission is given regulatory oversight concerning the bill’s provisions.

SUMMARY AS INTRODUCED:

Health insurance; fair business practices. Establishes fair business practices standards applicable to the claim reimbursement practices of health insurance carriers, health services plans and HMOs (referred to as “carriers”). The section requires carriers to (i) pay claims within 45 days of claim receipt, unless the claim is unreasonable, is disputed, or there is otherwise no obligation to pay, (ii) contact health care providers within 15 days of receiving reimbursement claims if they desire further claim documentation, and (iii) establish reasonable policies giving providers notice of required administrative claims processing procedures in advance of submitting claims. The legislation also prohibits retroactive claim denial unless claims are fraudulent, previously paid, or retroactively reviewed in less than 180 days following the date the claims are paid. The Virginia State Corporation Commission is given authority to investigate allegations of violations arising under this bill, but not to adjudicate individual disputes. However, the legislation establishes private rights of action for providers who suffer actual damages resulting from carrier violations of the provisions. Providers are entitled to recover the greater of $1,000 or treble damages for any willful violations of this new section.