August 1998 Bulletin

Study prompt pay rules

The Delaware Insurance Commissioner and the New Jersey Department of Health and Senior Services have proposed rules that would require prompt payment by HMOs.

New Jersey's proposed rules are meant to clarify terms in existing statutes that require HMOs to pay the uncontested portion of any claim within 60 days of receiving it and to explain in writing to the member or provider the reason for contesting or denying a claim within 45 days of receiving it.

Delaware's rules would require HMOs and insurers to pay claims and bills within 45 days of receiving them except in cases which the obligation to pay is unclear or there is evidence the claim is fraudulent. If the obligation to pay a claim is not clear, the regulations call for the undisputed portion of the claim to be paid within 45 days.

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