Claims Payment Requirements
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
Timely processing of claims is monitored via the participating physician group's (PPG's) and capitated hospital'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.
Claims Payment
Claims received on or after January 1, 2026 must reimbursed fully or partially within 30 calendar days of receipt. If a claim is incomplete, the physician or other provider must be notified as soon as possible, and no later than 30 calendar days after receiving the claim.
Interest and Penalty Payments for Late Claims
For claims received prior to January 1, 202, PPGs and capitated hospitals 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 the check must be mailed within five days of the resolution letter, including interest if applicable).
For claims received after January 1, 2026,
- Process 95 percent of commercial HMO claims within 30 calendar days of receipt.
- Late paid claims must include interest at the rate of 15% per annum beginning with the first calendar day after the 30-calendar day period.
- Failure to automatically include all interest that has accrued on a late payment of a claim requires a penalty payment to the claimant the greater of either an additional $15 or 10% of the accrued interest on the claim.
- Resolve 95 percent of provider disputes within 45 business days (if a provider dispute is in favor of the provider the check must be mailed within five days of the resolution letter, including interest if applicable).
Member Notices About Incomplete Claims
PPGs and capitated hospitals must notify the member and provider in writing within 30 calendar days from receipt of the claim of an incomplete claim. Notices must specify:
- Date of denial notice.
- Member name.
- Provider name.
- Specific service.
- Date of service.
- Denied amount.
- Member responsibility amount.
- Reason for the denial - Claim denials for members must include a claim denial message.
- Provider and member appeals process and information, including plan name, address and telephone number for appeals.