Download as PDF
304.17A-706 Contested claims -- Delay of payment -- Conditions -- Procedure.
(1)
(2)
(3)
An insurer may contest a clean claim only in the following instances:
(a) The insurer has reasonable documented grounds to believe that the
clean claim involves a preexisting condition, coordination of benefits
within the meaning of KRS 304.18-085, or that another insurer is primarily
responsible for the claim;
(b) The insurer will conduct a retrospective review of the services identified
on the claim;
(c) The insurer has information that the claim was submitted fraudulently; or
(d) The covered person's or group's premium has not been paid.
(a) If an insurer requires a provider to submit health claim attachments to the
claim before the claim will be paid, the insurer shall identify the specific
required health claim attachments in its provider manual or other
document that sets forth the procedure for filing claims with the insurer.
The insurer shall provide sixty (60) days' advance written notice of
modifications to the provider manual that materially change the type or
content of the health claim attachments or other documents to be
submitted.
(b) If a provider submits a clean claim with the required health claim
attachments as specified in the provider manual or other document that
sets forth the procedure for filing claims with the insurer, the insurer shall
pay or deny the claim within the required claims payment time frame
established in KRS 304.17A-702.
(c) If an insurer conducts a retrospective review of a claim and requires an
attachment not specified in the provider manual or other document that
sets forth the procedure for filing claims, the insurer shall:
1.
Notify the provider, in writing or electronically within the claims
payment time frame established in KRS 304.17A-702, of the service
that will be retrospectively reviewed and the specific information
needed from the provider regarding the insurer's review of a claim;
2.
Complete the retrospective review within twenty (20) business days
of the insurer's receipt of the medical information described in this
subsection; and
3.
Subject to paragraph (d) of this subsection, add interest to the
amount of the claim, to be paid at a rate of twelve percent (12%) per
annum, or at a rate in accordance with KRS 304.17A-730, accruing
from the appropriate claim payment time frame established in KRS
304.17A-613 after the claim was received by the insurer through the
date upon which the claim is paid.
(d) If the provider fails to submit the information requested under
subparagraph (c) 1. of this subsection within fifteen (15) business days
from the date of the receipt of the notice, the insurer shall not be required
to pay interest.
(a) If a claim or portion thereof is contested by an insurer on the basis that
the insurer has not received information reasonably necessary to
(b)
determine insurer liability for the claim or portion thereof, or if the insurer
contests the claim on the reasonable and documented belief that the
claim involves the coordination of benefits within the meaning of KRS
304.18-085, or questions of pre-existing conditions, the insurer shall,
within the applicable claims payment time frame established in KRS
304.17A-702, provide written or electronic notice to the provider, covered
person, group policyholder, or other insurer, as appropriate, with an
itemization of all new, never-before-provided information that is needed.
The insurer shall pay or deny the claim within thirty (30) calendar days of
receiving the additional information described in paragraph (a) of this
subsection. If the insurer does not receive the additional information
described in paragraph (a) of this subsection within fifteen (15) business
days from the date of receipt of the notice set forth in paragraph (a) of this
subsection, the insurer may deny the claim. Any claim denied under this
paragraph may be resubmitted by the provider and any resubmitted claim
shall not be denied on the basis of timeliness if the resubmitted claim is
made with the timeframe for submitting claims established by the insurer
beginning on the date of denial.
Effective:July 15, 2002
History: Amended 2002 Ky. Acts ch. 181, sec. 14, effective July 15, 2002. -Created 2000 Ky. Acts ch. 436, sec. 4, effective July 14, 2000.
Disclaimer: These codes may not be the most recent version. Kentucky may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.