Rule 120-2-8-.13. Standards for Claims Payment

1. (1) An issuer shall comply with Section 1882(c)(3) of the Social Security Act (as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Pub. L. No. 100-203) by:

   1. (a) Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;
   2. (b) Notifying the participating physician or supplier and the beneficiary of the payment determination;
   3. (c) Paying the participating physician or supplier directly;
   4. (d) Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number and a central mailing address to which notices from a Medicare carrier may be sent;
   5. (e) Paying user fees for claim notices that are transmitted electronically or otherwise; and
   6. (f) Providing to the Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.
2. (2) Compliance with the requirements set forth in Subsection (1) above shall be certified on the Medicare supplement insurance experience reporting form.

Authority: O.C.G.A. Secs. 33-2-9, 33-43-3, 33-43-4, 33-43-5, 33-43-6.

History. Original Rule entitled "Requirements for Replacement" adopted. F. Aug. 24, 1989; eff. Sept. 15, 1989, as specified by the Agency.

Repealed: New Rule entitled "Required Disclosure Provisions" adopted. F. Sept. 18, 1990; eff. Dec. 1, 1990, as specified by the Agency.

Repealed: New Rule entitled "Standards for Claims Payment" adopted. F. Jul. 9, 1992; eff. July 29, 1992.

Amended: ER. 120-2-8-0.4-.13 adopted. F. Apr. 30, 1996, eff. Apr. 28, 1996, as specified by the Agency.

Amended: Permanent Rule entitled "Loss Ratio Standards and Refund or Credit of Premium" adopted. F. Sept. 6, 1996; eff. Sept. 26, 1996.

Repealed: New Rule entitled "Standards for Claims Payment" adopted. F. Apr. 7, 1999; eff. Apr. 27, 1999.

Repealed: New Rule of same title adopted. F. Aug. 19, 2005; eff. Sept. 8, 2005.

Amended: ER. 120-2-8-0.22-.13 of same title adopted. F. May 29, 2009; eff. June 1, 2009, as specified by the Agency.

Amended: Permanent Rule of same title adopted. F. Sept. 3, 2009; eff. Sept. 23, 2009.