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).