1. (a) The provisions of this section shall only apply to persons that are defined as health carriers under 23 CAR § 15-103(b)(8).

2. (b)

   1. (1) If the resolution of the claim requires the health carrier to obtain additional information to resolve one (1) or more of the issues listed in subsection (c) of this section, the health carrier shall, within thirty (30) days after receipt of the claim, notify the health claimant.
   2. (2) The health carrier’s notice shall give an explanation of the additional information that is required.
   3. (3) The health carrier may suspend the claim until it receives the requested information, or in the case of a Medicare supplement policy, the claim may be suspended until the health carrier receives the EOMB.

3. (c) When there is a reasonable basis for doing so, a health carrier may request one (1) or more of the following items to resolve the claim:

   1. (1) Information in order to determine if a health insurance contract limitation or exclusion is applicable to the claim;
   2. (2) Medical information in order to determine the price for a medical procedure without a Current Procedural Terminology (CPT) code or a Health Care Financing Administration Common Procedure Coding System (HCPCS) code;
   3. (3) Information in order to determine if a health insured who received the claimed services is eligible under the terms of the health insurance contract;

   4. (4) Information in order to determine if the claim is covered by:

      1. (A) Another health carrier;
      2. (B) Workers’ compensation;
      3. (C) A government supported program; or
      4. (D) A liable third party;
   5. (5) Information in order to determine the obligation of each health carrier or government program under coordination of benefits rules;
   6. (6) Information in order to determine if there has been fraud or a fraudulent or material misrepresentation with respect to the claim; or
   7. (7) Payment from the policyholder of premiums that were delinquent at the time the claimed services were rendered.
4. (d) A health carrier shall reopen and pay or deny a previously suspended claim within thirty (30) days after the health carrier receives all the information it requested.

5. (e)

   1. (1) A health carrier which fails to pay or deny a claim in accordance with subsection (d) of this section, and that is not already subject to the penalty for the claim imposed by 23 CAR § 15-110(d), shall pay a penalty to the health claimant for the period beginning on the forty-sixth day after the last item of information requested was received and ending on the claim payment date (the delinquent payment period), calculated as follows.
   2. (2) The amount of the claim payment multiplied by twelve percent (12%) per annum multiplied by the number of days in the delinquent payment period, divided by three hundred sixty-five (365).
   3. (3) Such penalty shall be paid without any further action by the health claimant.

Codification Notes: "EOMB" means explanation of Medicare benefits.