State Department of Insurance Website

California https://www.insurance.ca.gov
Hawaii http://cca.hawaii.gov/ins/
Idaho http://www.doi.idaho.gov
Illinois http://insurance.illinois.gov
Indiana http://www.in.gov/idoi
Iowa www.iid.state.ia.us
Kansas http://www.ksinsurance.org/
Kentucky http://insurance.ky.gov/
Louisiana http://www.ldi.state.la.us/
Maine http://www.maine.gov/pfr/insurance
Maryland http://www.mdinsurance.state.md.us/
Statute/Code Section Time period to pay or deny claim

• HMO: 45 business days

• PPO: 30 business days
28 CCR 1300.71
 greater of $15
per claim for
each 12-month
period or 15%
APR interest is
Notice period for unclean claim (Penalty
due Notification requirement when provider manual changes?
• Non-ER
Claims: When
claim is not paid
or contested
within 30-45
working days
(PPO-HMO),
15% APR
interest is due
Rules on health plan modification of contract Pre-authorization & Pre-certification requirements
o Consider nature of the services
provided
o Consider the fees usually charged
by the provider
o Consider prevailing/common
Using Usual
provider rates&charged
Customary rates
in the laws Timely Claim submission deadline
general
geographic area in which the services
were rendered
o Consider other information relevant
to provider’s business
o Consider any unusual circumstance
specific to the claim.
• FOR non ER Claims by non-
participating provider: Payer shall
pay based on patient’s benefit policy
a.k.a evidence of coverage.
Rules when provider claim is untimely. Does health plan have to accept untimely claims
Include if there is a clean claim definition Time limit to pay or deny claim

means a claim or portion thereof, if separable, including

attachments and supplemental information or
documentation, which provides: "reasonably relevant
information" as defined by section (a)(10), "information
necessary to determine payer liability" as defined in section
(a)(11) and
Time limit to request for additional information from provider Provider Appeal deadlines
Independent & External Review process Overpayment Recoupment law

28 CCR 1300.71
None
None
None
Burns Ind. Code Ann. § 27-8-5.7-10(a)
191 IAC 15.33
None
KRS § 304.17A-708(3)

24-A M.R.S. § 4303

Md. INSURANCE Code Ann. § 15-1008
Overpayment recoupment deadline Overpayment recoupment
• Notice of overpayment otherberequirement
MUST in a
separate writing
• Within 365 days
• Clearly identify Claim, Patient, Date of
Service
• Clear explanation on basis/reason why
payer believes claim was overpaid.
• EXCEPTION: Provider Fraud or
misrepresentation is excluded and this
guideline would not apply
365 days from date of payment
None
None
None
24 months from date of payment
2 years from date of claim submission
None
24 months from date of payment
No Limit
12 months from date of payment
6 months from date of payment
 responsibi
lity. This
obligation
may be
affected
Overpayment recoupment through offset Provider complaints to department of insurance Escalation
by any steps within health
"correctiv
e action
Payer must provide notice AND allow 30 plan" the
working days for provider to respond AND health
there is prior contractual agreement that plan has
allows payer to recover overpayment put in
through offset place with
the
IPA/MG/
DOI or DMHC Complaint through website TPA
Escalation steps within health plan