N.J. Admin. Code § 11:22-1.5

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:22-1.5 - Prompt payment of claims

(a) A carrier and its agent shall remit payment of clean claims pursuant to the following time frames:

1. Thirty calendar days after receipt of the claim where the claim is submitted by electronic means or the time established for the Federal Medicare program by 42 U.S.C. § 1395u(c)2(B), whichever is earlier; or

2. Forty calendar days after receipt of the claim where the claim is submitted by other than electronic means.

(b) Carriers and their agent shall pay claims that are disputed or denied because of missing information or substantiating documentation within 30 or 40 calendar days of receipt of the missing information or substantiating documentation, as applicable, pursuant to (a) above.

(c) No health carrier or its agent shall deny, delay, or pend payment of a claim in whole or in part while seeking information as to whether the covered person has other insurance that may be primary, unless good cause exists for the health carrier or its agent to believe that other coverage is available to the covered person. Good cause shall exist only if the health carrier's or agent's records indicate that the covered person has coverage under another health benefits or prescription drug plan. Routine requests to determine whether additional coverage exists shall not be considered good cause.

(d) Payment of a claim shall be considered to have been made:

1. On the date a draft or other valid instrument equivalent to payment was placed in the United States mail in a postpaid envelope containing the most recent address filed by the provider with the carrier or its agent; or

2. If not paid pursuant to (d)1 above, on the date of delivery to the payee of a draft or other valid instrument equivalent to payment.

(e) If a dental plan organization or dental service corporation fails to pay a clean claim under a dental plan within the time limits set forth in this section, it shall include simple interest on the claim amount at the rate of 10 percent per year and shall add the interest amount to the claim amount when paying the claim. If a health carrier or its agent fails to pay a clean claim within the time limits set forth in this section, the health carrier or its agent shall include simple interest on the claim amount at the rate of 12 percent per year and shall include the interest amount with the claim amount at the time the overdue claim is paid. For all carriers, interest shall accrue beginning 30 or 40 days, as applicable, from the date all information and documentation required to process the claim is received by the carrier.

(f) A carrier or its agent shall maintain an auditable record of when payments were transmitted to health care providers or covered persons whether by United States mail or otherwise.

N.J. Admin. Code § 11:22-1.5

Recodified from 11:22-1.6 by 50 N.J.R. 571(a), effective 1/16/2018

Amended by 50 N.J.R. 829(a), effective 2/5/2018