WEST virginia Legislature
2017 regular session
By
to the Committee on Banking and Insurance; and then to the Committee on Health
and Human Resources]
A BILL to amend and
reenact §33-45-2 of the Code of West Virginia, 1931, as amended, relating to
defining the criteria which private insurance carriers operating in West Virginia
must consider in setting rates to providers of health care services.
Be it enacted by the Legislature
of West Virginia:
That §33-45-2 of the
Code of West Virginia, 1931, as amended, be amended and reenacted to read as
follows:
ARTICLE 45. ETHICS AND
FAIRNESS IN INSURER BUSINESS PRACTICES.
§33-45-2. Minimum fair
business standards contract provisions required; processing and payment of
health care services; provider claims; commissioner's jurisdiction.
(a) Every provider contract
entered into, amended, extended or renewed by an insurer on or after August 1,
2001, shall contain specific provisions which shall require the insurer to
adhere to and comply with the following minimum fair business standards in the
processing and payment of claims for health care services:
(1) An insurer shall either
pay or deny a clean claim within forty days of receipt of the claim if
submitted manually and within thirty days of receipt of the claim if submitted
electronically, except in the following circumstances:
(A) Another payor or party
is responsible for the claim;
(B) The insurer is
coordinating benefits with another payor;
(C) The provider has
already been paid for the claim;
(D) The claim was submitted
fraudulently; or
(E) There was a material
misrepresentation in the claim.
(2) Each insurer shall
maintain a written or electronic record of the date of receipt of a claim. The
person submitting the claim shall be entitled to inspect the record on request
and to rely on that record or on any other relevant evidence as proof of the
fact of receipt of the claim. If an insurer fails to maintain an electronic or
written record of the date a claim is received, the claim shall be considered
received three business days after the claim was submitted based upon the
written or electronic record of the date of submittal by the person submitting
the claim.
(3) An insurer shall,
within thirty days after receipt of a claim, request electronically or in
writing from the person submitting the claim any information or documentation
that the insurer reasonably believes will be required to process and pay the
claim or to determine if the claim is a clean claim. The insurer shall use all
reasonable efforts to ask for all desired information in one request, and shall
if necessary, within fifteen days of the receipt of the information from the
first request, only request or require additional information one additional
time if such the additional information could not have been
reasonably identified at the time of the original request or to specifically
identify a material failure to provide the information requested in the initial
request. Upon receipt of the information requested under this subsection which
the insurer reasonably believes will be required to adjudicate the claim or to
determine if the claim is a clean claim, an insurer shall either pay or deny
the claim within thirty days. No insurer may refuse to pay a claim for health
care services rendered pursuant to a provider contract which are covered
benefits if the insurer fails to timely notify the person submitting the claim
within thirty days of receipt of the claim of the additional information
requested unless such failure was caused in material part by the person
submitting the claims: Provided, That nothing herein shall preclude
precludes such an the insurer from imposing a retroactive denial of
payment of such a the claim if permitted by the provider contract
unless such the retroactive denial of payment of the claim would
violate subdivision (7), subsection (a) of this section. This subsection does
not require an insurer to pay a claim that is not a clean claim except as
provided herein.
(4) Interest, at a rate of
ten percent per annum, accruing after the forty-day period provided in
subdivision (1), subsection (a) of this section owing or accruing on any claim
under any provider contract or under any applicable law, shall be paid and
accompanied by an explanation of the assessment on each claim of interest paid,
without necessity of demand, at the time the claim is paid or within thirty
days thereafter.
(5) Every insurer shall
establish and implement reasonable policies to permit any provider with which
there is a provider contract:
(A) To promptly confirm in
advance during normal business hours by a process agreed to between the parties
whether the health care services to be provided are a covered benefit; and
(B) To determine the
insurer's requirements applicable to the provider (or to the type of health
care services which the provider has contracted to deliver under the provider
contract) for:
(i) Precertification or
authorization of coverage decisions;
(ii) Retroactive
reconsideration of a certification or authorization of coverage decision or
retroactive denial of a previously paid claim;
(iii) Provider-specific
payment and reimbursement methodology; and
(iv) Other
provider-specific, applicable claims processing and payment matters necessary
to meet the terms and conditions of the provider contract, including
determining whether a claim is a clean claim.
(C) Every insurer shall
make available to the provider within twenty business days of receipt of a request,
reasonable access either electronically or otherwise, to all the policies that
are applicable to the particular provider or to particular health care services
identified by the provider. In the event the provision of the entire policy
would violate any applicable copyright law, the insurer may instead comply with
this subsection by timely delivering to the provider a clear explanation of the
policy as it applies to the provider and to any health care services identified
by the provider.
(6) Every insurer shall pay
a clean claim if the insurer has previously authorized the health care service
or has advised the provider or enrollee in advance of the provision of health
care services that the health care services are medically necessary and a
covered benefit, unless:
(A) The documentation for
the claim provided by the person submitting the claim clearly fails to support
the claim as originally authorized; or
(B) The insurer's refusal
is because:
(i) Another payor or party
is responsible for the payment;
(ii) The provider has
already been paid for the health care services identified on the claim;
(iii) The claim was
submitted fraudulently or the authorization was based in whole or material part
on erroneous information provided to the insurer by the provider, enrollee, or
other person not related to the insurer;
(iv) The person receiving
the health care services was not eligible to receive them on the date of
service and the insurer did not know, and with the exercise of reasonable care
could not have known, of the person's eligibility status;
(v) There is a dispute
regarding the amount of charges submitted; or
(vi) The service provided
was not a covered benefit and the insurer did not know, and with the exercise
of reasonable care could not have known, at the time of the certification that
the service was not covered.
(7) A previously paid claim
may be retroactively denied only in accordance with this subdivision.
(A) No insurance company
may retroactively deny a previously paid claim unless:
(i) The claim was submitted
fraudulently;
(ii) The claim contained
material misrepresentations;
(iii) The claim payment was
incorrect because the provider was already paid for the health care services
identified on the claim or the health care services were not delivered by the
provider;
(iv) The provider was not
entitled to reimbursement;
(v) The service provided
was not covered by the health benefit plan; or
(vi) The insured was not
eligible for reimbursement.
(B) A provider to whom a
previously paid claim has been denied by a health plan in accordance with this
section shall, upon receipt of notice of retroactive denial by the plan, notify
the health plan within forty days of the provider's intent to pay or demand written explanation of the
reasons for the denial.
(i) Upon receipt of
explanation for retroactive denial, the provider shall reimburse the plan
within thirty days for allowing an offset against future payments or provide
written notice of dispute.
(ii) Disputes shall be
resolved between the parties within thirty days of receipt of notice of
dispute. The parties may agree to a process to resolve the disputes in a
provider contract.
(iii) Upon resolution of
dispute, the provider shall pay any amount due or provide written authorization
for an offset against future payments.
(C) A health plan may
retroactively deny a claim only for the reasons set forth in subparagraphs
(iii), (iv), (v) and (vi), paragraph (A) of this subdivision (7) for a period
of one year from the date the claim was originally paid. There shall be no time
limitations for retroactively denying a claim for the reasons set forth in
subparagraphs (i) and (ii) above.
(8) No provider contract
may fail to include or attach at the time it is presented to the provider for
execution:
(A) The fee schedule,
reimbursement policy or statement as to the manner in which claims will be
calculated and paid which is applicable to the provider or to the range of
health care services reasonably expected to be delivered by that type of
provider on a routine basis; and
(B) The manner in which
reimbursement is calculated by the insurer:
Provided, That in setting
reimbursement rates for any provider that is subject to the provisions of
article five-b, chapter sixteen of this code rates are required to be set by
comparison of similar providers within the geographic area of the
provider: Provided, however, That reimbursement rates may not be set by
comparison of rates of any out of state facility regardless of its proximity to
any provider licensed under the provisions of article five-b, chapter sixteen
of this code; and
(B) (C) All material addenda, schedules and
exhibits thereto applicable to the provider or to the range of health care
services reasonably expected to be delivered by that type of provider under the
provider contract.
(9) No amendment to any
provider contract or to any addenda, schedule or exhibit, or new addenda,
schedule, exhibit, applicable to the provider to the extent that any of them
involve payment or delivery of care by the provider, or to the range of health
care services reasonably expected to be delivered by that type of provider, is
effective as to the provider, unless the provider has been provided with the
applicable portion of the proposed amendment, or of the proposed new addenda,
schedule or exhibit, and has failed to notify the insurer within twenty
business days of receipt of the documentation of the provider's intention to
terminate the provider contract at the earliest date thereafter permitted under
the provider contract.
(10) In the event that
If the insurer's provision of a policy required to be provided under
subdivision (8) or (9) of this subsection would violate any applicable
copyright law, the insurer may instead comply with this section by providing a
clear, written explanation of the policy as it applies to the provider.
(11) The insurer shall
complete a credential check of any new provider and accept or reject the
provider within four months following the submission of the provider's completed application: Provided, That time
frame may be extended for an additional three months because of delays in
primary source verification. The insurer shall make available to providers a
list of all information required to be included in the application. A provider
who is permitted by the insurer to provide services and who provides services
during the credentialing period shall be paid for the services if the provider's application is approved.
(b) Without limiting the
foregoing, in the processing of any payment of claims for health care services
rendered by providers under provider contracts and in performing under its
provider contracts, every insurer subject to regulation by this article shall
adhere to and comply with the minimum fair business standards required under
subsection (a) of this section. The commissioner has jurisdiction to may
determine if an insurer has violated the standards set forth in subsection (a)
of this section by failing to include the requisite provisions in its provider
contracts. The commissioner has jurisdiction to may determine if
the insurer has failed to implement the minimum fair business standards set out
in subdivisions (1) and (2), subsection (a) of this section in the performance
of its provider contracts.
(c) No insurer is in
violation of this section if its failure to comply with this section is caused
in material part by the person submitting the claim or if the insurer's
compliance is rendered impossible due to matters beyond the insurer's
reasonable control, such as an act of God, insurrection, strike, fire, or power
outages, which are not caused in material part by the insurer.
NOTE: The purpose of this bill is
to define the criteria which private insurance carriers operating in West
Virginia must consider in setting rates.
The bill provides that in setting reimbursement rates for any provider
that is subject to the provisions of article five-b, chapter sixteen of this
code rates are required to be set by comparison of similar providers within the
geographic area of the provider and that reimbursement rates may not be set by
comparison of rates of any out-of-state facility regardless of its proximity to
any provider of health care services licensed under the provisions of article
five-b, chapter sixteen of this code.
Strike-throughs indicate language
that would be stricken from a heading or the present law and underscoring
indicates new language that would be added.