Claims Payment Requirements

Provider Type

  • Participating Physician Groups (PPG)
  • Hospitals

Timely processing of claims is monitored via the participating physician group's (PPG's) self-reported monthly claims timeliness reports. Accuracy and timely processing of claims is verified by routine and targeted audits conducted by the Delegation Oversight staff.

PPGs are required to:

  • Process 95 percent of commercial HMO claims within 45 business days of receipt.
  • Pay 15 percent interest or $15 per year, whichever is greater, on late paid claims for emergency services rendered in the United States.
  • Pay 15 percent interest on late paid claims and include an additional penalty fee of $10 if the interest is not included with the original claims payment.
  • Pay 15 percent interest on late paid claims for non-emergency services rendered in the United States.
  • Resolve 95 percent of provider disputes within 45 business days (if a provider dispute is in favor of the provider check, this needs to be mailed within five days of the resolution letter, including interest if applicable).