Enrolled Bill Summary

            Senate Bill 418 amends the Insurance Code to establish new prompt payment regulations for transactions between health care providers and insurers, including preferred provider organizations and health maintenance organizations (HMOs). The bill establishes the elements of a clean claim and sets out procedures for a physician, provider, or preferred provider to submit a claim and for the insurer or HMO to process that claim. It establishes specific deadlines for an HMO to take action on clean claims, audited claims, and certain prescription claims. It provides for an insurer or HMO to obtain additional information to determine payment of a claim and establishes guidelines for the electronic submission of a claim. The bill requires the claims payment processes used by an insurer or HMO to include codes, guidelines, logics, and edits that are nationally recognized and generally accepted and provides for a physician, provider, or preferred provider to obtain copies of coding guidelines and fee schedules. The bill authorizes an insurer or HMO to recover an overpayment to a physician or provider if certain requirements are met and sets out requirements for coordinating the payment of claims to the appropriate parties. It establishes penalties for a violation of the requirements for claims payments and establishes that prompt payment and verification provisions apply to a physician or provider who is not a preferred provider but provides emergency care or certain specialized medical or health care services. The bill requires an identification card or similar document issued by an insurer or HMO to an insured or enrollee to display certain plan information. It requires the commissioner of insurance to waive the application of any of the above provisions if the commissioner determines, in consultation with the commissioner of health and human services, that the provision will cause a negative fiscal impact on the state. The bill requires the commissioner to appoint a technical advisory committee on claims processing and establishes the duties and responsibilities of that committee.