Claims Payment Requirements

Timely payment of claims is monitored via delegated entities' monthly timeliness report (MTR), and is verified by routine and targeted audits conducted by the Delegation Oversight staff. Delegated entities are not required to send Explanation of Benefits (EOB) to Medicare Advantage (MA) members. However, the data used for the EOBs must continue to be provided to the plan by delegated entities at the time of the Delegation Oversight Audit. Additionally, as required by Centers for Medicare and Medicaid Services (CMS), the data provided is also used by the plan to produce EOBs.

Delegated entities are required to comply with the following:

• Process 95 percent of MA clean claims from non-affiliated providers within 30 calendar days, and all other MA claims within 60 calendar days of receipt.
• Process MA provider disputes within 30 calendar days from receipt.
• The current published Centers for Medicare and Medicaid (CMS) interest rate is paid on all non-affiliated late claims.

MA claims that are not processed within the requirement thresholds are considered noncompliant with CMS regulations.