PURPOSE: This rule effectuates or aids in the interpretation of section 375.1007, RSMo 2000, and sections 376.383 and 376.384, RSMo Supp. 2008.

1. (1) Scope. This rule applies to all claims submitted by a claimant to a health carrier or its third-party contractor after September 1, 2009, and that health benefit plan is either a fully-insured group health benefit plan where the provider submits claims as a participating provider or is an individual health benefit plan.

2. (2) Definitions. As used in sections 376.383 and 376.384, RSMo, and in the regulations promulgated pursuant thereto—

   1. (A) “Acknowledgment of the date of receipt” shall mean a written notice, whether made in electronic or nonelectronic format, to the claimant by the health carrier or its third-party contractor that it received a claim and setting forth the date on which the claim was received;
   2. (B) “Claim” shall mean a written request or demand by a claimant for the payment of health care services provided, whether made in an electronic format by a provider or in an electronic or nonelectronic format by an insured or enrollee;
   3. (C) “Confirmation of receipt” shall mean a written notice, made in electronic or nonelectronic format, to the health care provider by the health carrier or its third-party contractor that it received an electronically-filed claim. A confirmation of receipt may also constitute an acknowledgement of the date of receipt if it meets the requirements of subsection (A) of this section;

   4. (D) “Date of claim payment” shall mean the date the health carrier or its third-party contractor mails or sends the payment as indicated by the date of—

      1. 1. The postmark, if a claim payment is

delivered by the U.S. Postal Service;

1. 2. The electronic transmission, if the

payment is made electronically;

1. 3. The delivery of the claim payment by

a courier; or

1. 4. The receipt by the claimant, if the

claim payment is made other than as provided in paragraphs (2)(D)1. through (2)(D)3., above;

1. (E) “Date of denial” shall mean the date when the health carrier or its third-party contractor mails or electronically sends a denial;

2. (F) “Date of receipt” shall mean the date upon which the health carrier or its thirdparty contractor first receives a claim or other information relevant and pertinent to the claim, indicated by the date of—

   1. 1. Presumed receipt in subsection

(3)(B), below, if a claim is delivered in that manner;

1. 2. The electronic transmission, if the

claim is delivered electronically; or

1. 3. The date stamped by the health carri-

er or its third-party contractor, if the claim is delivered in a manner other than those described above;

1. (G) “Deny” or “denial” shall mean the health carrier or its third-party contractor mails or sends an electronic or written notice to the claimant refusing to reimburse all or part of the claim, which includes each reason for the denial;
2. (H) “Health benefit plan” shall mean health benefit plan as defined in section 376.1350, RSMo;
3. (I) “Notification of claim” shall mean any notification to a carrier or its third-party contractor, by a claimant, which reasonably apprises the health carrier of the facts pertinent to a claim;
4. (J) “Pay” or “payment” shall mean the health carrier or its third-party contractor mails or sends electronic or written notice including remuneration to the claimant that reimburses all or part of the claim;
5. (K) “Processing days” shall mean the number of days the health carrier or its third-party contractor has the claim in its possession. Processing days shall not include days in which the health carrier is waiting for a response to a reasonable request for additional necessary information;

6. (L) “Request for additional information” shall mean when the health carrier or its third-party contractor requests, in writing, whether made in electronic or nonelectronic format, additional necessary information from the claimant to determine if all or part of the claim will be reimbursed. Such a request must meet the following requirements:

   1. 1. It shall describe with specificity the

clinical and other information to be included in the response; and

1. 2. It shall be relevant and necessary for

the resolution of the claim;

1. (M) “Suspension date” shall mean the date the health carrier or its third-party contractor mails or sends electronic written notice that the claim is suspended;
2. (N) “Third-party contractor” shall mean an entity or person contracted with the health carrier to receive or process claims for reimbursement of health care services; and
3. (O) “Working days” shall mean the number of consecutive days not counting weekends or federal holidays.

1. (3) Communications Between Entities Subject to This Rule.

   1. (A) An entity subject to this rule may deliver written communication as follows:

      1. 1. By U.S. mail, first-class delivery; by

U.S. mail, return receipt requested; or by overnight mail, and maintain a copy of the receipt or signature card acknowledging receipt of delivery;

1. 2. Electronically and maintain proof of

the electronically submitted communication;

1. 3. If the entity accepts facsimile trans-

missions for the type of communication being sent, then fax the communication and maintain proof of the facsimile transmission; or

1. 4. Hand delivery of the communication

and maintain a copy of the signed receipt acknowledging the hand delivery.

1. (B) Communication is presumed to be received as follows:

   1. 1. On the date shown by a date stamp

showing the actual date received, if the sender used U.S. mail, first-class delivery; or

1. 2. On the date the delivery receipt is

signed, if the sender used an overnight delivery service or the U.S. mail, return receipt requested, or if the sender hand delivered the communication.

1. (4) Standards for Prompt, Fair, and Equitable Settlements under Health Benefit Plans.

   1. (A) Every health carrier or third-party contractor, upon receiving notification of a claim from a claimant, shall, within ten (10) working days, do one (1) or more of the following—

      1. 1. Send an acknowledgment of the date

of receipt;

1. 2. Send written notice of status of the

claim, whether made in electronic or nonelectronic format, with a request for additional information and from whom it is requested, such as the claimant, the patient, or another health care provider;

1. 3. Pay the total amount of the claim in

accordance with the contract between the health carrier and the health care provider or the health carrier and the insured or enrollee;

1. 4. Pay the portion of the claim for which

the health carrier acknowledges liability in accordance with the contract between the health carrier and the health care provider or the health carrier and the insured or enrollee, suspend the remainder of the claim, and send a request for additional information;

1. 5. Pay the portion of the claim for which

the health carrier acknowledges liability in accordance with the contract between the health carrier and the health care provider or the health carrier and the insured or enrollee, and deny a portion of the claim and specify each reason for the denial; or

1. 6. Deny the claim in its entirety and

specify each reason for such denial.

1. (B) If notice of the claim was received as an electronically filed claim, the health carrier or its third-party contractor shall issue confirmation of receipt of the claim within one (1) working day of its receipt to the claimant that submitted the claim electronically.
2. (C) If additional information is requested, an appropriate reply shall be made within fifteen (15) processing days of receiving any additional claim information from the person from whom the information was requested. An appropriate reply shall mean payment of all or the undisputed portion of the claim, denial of the claim, suspension of the claim, or a final request for additional information.
3. (D) All denials, suspensions, or requests for additional information shall be communicated in writing to the claimant and shall include specific reasons why the action was taken or why the information is needed.

1. (5) Health carriers must conduct a reasonable investigation before denying or suspending a claim in whole or in part. Health carriers shall not suspend or deny claims for lack of information until it has requested the pertinent additional information on two (2) separate occasions.

   1. (A) Claims.

      1. 1. If a claim or portion of a claim

remains unpaid after forty-five (45) days after notification of the claim, interest shall accrue beginning from the forty-fifth day after the date of receipt of the claim at a rate equal to one percent (1%) per month of the unpaid balance of the claim until the claim is paid. The interest shall be payable by the health carrier to the health care provider, individual insured, enrollee, or other entity submitting the claim. If the health carrier denies or suspends a claim that is subsequently determined to be the liability of the health carrier, the health carrier will be responsible for the interest from the forty-fifth day of the original date of notification of the claim until the claim is actually paid.

1. 2. Any improperly denied claims that

are subsequently determined to be payable shall have interest calculated from the fortyfifth day after the date of receipt of the claim.

1. 3. The health carrier may wait until the

claimant’s aggregate interest payments reach five dollars ($5) before making interest payment to the claimant.

1. (B) Duties of the Health Carrier.

   1. 1. When a health carrier pays or denies

a claim, it shall explain in sufficient detail how each item or service was reimbursed. Specifically, if the health carrier has a contract rate with the health care provider, the health carrier shall indicate which items or services are included in the reimbursement and which items are not included in the reimbursement.

1. 2. Pursuant to the requirements of 20

CSR 100-8.040, health carriers shall maintain and legibly date stamp all documentary material related to the pertinent events of a claim. Pertinent events shall include, but not be limited to, the date of the notification of claim, date of claim payment, date of denial, suspension date, reason for denial or suspension, amount paid, amount denied, amount suspended, date additional information is requested, the nature of the specific additional information requested, and the date such additional information was received.

1. 3. After notification of a claim, if any

information on the claim that affects the amount of benefits payable is changed or omitted in the processing of the claim, including any electronic edits, the health carrier or its third-party contractor shall notify the claimant of the modification in writing with specificity.

1. 4. Any contractual agreement between

the health carrier and any of its third-party contractors that receives or processes claims, obtains the service of a health care provider to provide health care services, or issues verifications or pre-authorizations may not be construed to limit the health carrier’s authority or responsibility to comply with all applicable statutory and regulatory requirements of this rule or of sections 376.383 and 376.384, RSMo.

1. 5. Contracts between health care

providers, health carriers, and their respective third-party contractors shall not extend the statutory or regulatory time frames set forth in this rule or in sections 376.383 and 376.384, RSMo.

1. (C) Complaints Against Health Carriers. Every complaint made by a health care provider to the director shall include: the health care provider’s name, address, and daytime phone number; the health carrier’s name; the date of service and date(s) the claim was filed with the health carrier; all relevant correspondence between the health 20 CSR 100-1

care provider and the health carrier, including requests from the health carrier for additional information; a copy of the confirmation of receipt or acknowledgment of the date of receipt of the claim from the health carrier or its third-party contractor, if available; and additional information which the health care provider believes would be of assistance in the department’s review.

AUTHORITY: section 376.1007, RSMo 2000 and sections 374.045, 376.383, and 376.384, RSMo Supp. 2008.* Original rule filed Sept. 5, 2008, effective May 30, 2009.

*Original authority: 374.045, RSMo 1967, amended 1993, 1995, 2008; 376.383, RSMo 1998, amended 2001; 376.384, RSMo 2001; and 376.1007, RSMo 1993.