(b) Every health carrier doing business in this state shall strive to meet the following claim timeliness standards for processing clean claims and other [23 CAR § 15-111] claims:

1. (1) Eighty-five percent (85%) of claims processed within thirty (30) days; and
2. (2) Ninety-eight percent (98%) of claims processed within forty-five (45) days.

(c)

1. (1) If requested by the Insurance Commissioner, a health carrier shall provide a claims processing report showing the percentage of clean claims and other claims the carrier processed for residents of this state during the previous quarter and year to date.

2. (2) The report will classify claims as follows:

   1. (A) Clean claims:

(i) Percent of claims processed within thirty (30) days following receipt of the claim;

1. (ii) Percent of claims processed within forty-five (45) days following receipt of the claim; and

   1. (iii) Percent of claims processed after forty-five (45) days following receipt of the claim; and

   2. (B) Other [23 CAR § 15-111] claims:

      1. (i) Percent of claims processed within thirty (30) days following reopening of the claim;
      2. (ii) Percent of claims processed within forty-five (45) days following reopening of the claims; and
      3. (iii) Percent of claims processed after forty-five (45) days following receipt of the claim.
      4. (d) If a claims processing report to the commissioner or other evidence obtained by the commissioner shows a health carrier’s clean claim or other [23 CAR § 15-111] health claim processing has fallen below the following regulatory action standards, sixty percent (60%) of claims processed within thirty (30) days or eighty-five percent (85%) of claims processed within forty-five (45) days:

2. (1)

   1. (A) The health carrier shall be required to submit to the commissioner a remedial action plan setting forth how and when its health claim processing shall be brought above the regulatory action standards.
   2. (B) In addition, at the commissioner’s option, the commissioner may conduct an onsite examination of the health carrier’s health claim processing;
3. (2) Depending upon the health carrier’s response, the commissioner, at his or her option, may require the health carrier to provide notice to its health claimants and contracted providers of delays in health claim processing and the steps being taken to improve this status;
4. (3) A health carrier which has failed to meet the regulatory action standards shall be required to provide the commissioner a claim processing report on a monthly basis until the health carrier meets the eighty-five percent (85%) and ninety-eight percent (98%) standards for both clean claim and other [23 CAR § 15-111] claim processing for two (2) consecutive quarters; and
5. (4) Nothing in this rule shall limit or restrict the commissioner from pursuing any other remedy or action against the health carrier under Arkansas Code § 23-66-201, nor act to limit any other administrative action against a health carrier under the Arkansas Insurance Code.

(e)

1. (1) A health carrier may be waived from the health claim processing standards under this section if its health claim processing system is seriously impacted by a natural disaster or if the health carrier obtains approval from the commissioner for a good cause shown.

2. (2) A health carrier, in requesting the commissioner’s waiver of the health claim processing standards, must:

   1. (A) Specify the reason or reasons;
   2. (B) Give its best estimate when the health claim processing standards will again be met; and
   3. (C) Commit to provide the commissioner periodic progress reports.

3. (3) In the case of a natural disaster, the health carrier shall:

   1. (A) Notify the commissioner as soon as possible after the event;
   2. (B) Specify when the claims system will be restored; and
   3. (C) Commit to submitting periodic progress reports to the commissioner.
4. (4) The commissioner shall publish a waiver granted to a health carrier on the State Insurance Department website.