Health Insurers/Claims Payment Process/Updates

This Act makes several changes intended to improve the claims payment process by health insurers. Specifically, the Act: (i) codifies the definition of “clean claim” adopted in Department of Insurance regulations; (ii) requires an insurer to treat erroneously denied claims as timely filed without the provider having to resubmit the claim; (iii) requires carriers that engaged in coordination of benefits verify an insured’s other coverage is effective for the date and type of service associated with the applicable claim before taking any recovery action against a provider; (iv) requires that a carrier who recovers payment from a provider through coordination of benefits and thereafter receives reimbursement for the same claim from another insurer issue notice to the provider of the payment so that the provider may seek payment for the amount recovered; (v) allows a provider 12 months to submit a claim for reimbursement after a retroactive denial by a carrier; (vi) requires prompt payment of clean claims within 30 days and after a successful appeal by a provider from a carrier’s denial of payment, with interest accruing on late payments. This Act also makes technical corrections to conform existing law to the standards of the Delaware Legislative Drafting Manual.

• John "Jack" WalshD
• Paul S. BaumbachD