Senate
File
504
-
Introduced
SENATE
FILE
504
BY
COMMITTEE
ON
COMMERCE
(SUCCESSOR
TO
SSB
1202)
A
BILL
FOR
An
Act
relating
to
timely
submission
of
claims
by
health
care
1
providers
to
health
insurers.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
3
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1492SV
(1)
88
ko/rn
S.F.
504
Section
1.
Section
507B.4,
subsection
3,
paragraph
p,
Code
1
2019,
is
amended
to
read
as
follows:
2
p.
Payment
of
interest.
Failure
of
an
insurer
to
pay
3
interest
at
the
rate
of
ten
percent
per
annum
on
all
health
4
insurance
claims
that
the
insurer
fails
to
timely
accept
5
and
pay
pursuant
to
section
507B.4A
507B.04B
,
subsection
6
2
,
paragraph
“d”
.
Interest
shall
accrue
commencing
on
the
7
thirty-first
day
after
receipt
of
all
properly
completed
proof
8
of
loss
forms.
9
Sec.
2.
Section
507B.4A,
Code
2019,
is
amended
by
striking
10
the
section
and
inserting
in
lieu
thereof
the
following:
11
507B.4A
Duty
to
respond
to
inquiries.
12
1.
A
person
shall
promptly
respond
to
an
inquiry
from
the
13
commissioner.
A
person’s
actions
are
deemed
untimely
under
14
this
section
if
the
person
fails
to
respond
to
an
inquiry
from
15
the
commissioner
within
thirty
days
of
the
receipt
of
the
16
inquiry,
unless
good
cause
exists
for
delay.
17
2.
Failure
to
respond
to
an
inquiry
from
the
commissioner
18
pursuant
to
this
section
with
such
frequency
as
to
indicate
a
19
general
business
practice
shall
subject
the
person
to
penalty
20
under
this
chapter.
21
Sec.
3.
NEW
SECTION
.
507B.04B
Timely
submission
of
claims
22
and
prompt
payment
of
claims.
23
1.
a.
For
purposes
of
this
section,
unless
the
context
24
otherwise
requires:
25
(1)
“Facility”
means
the
same
as
defined
in
section
26
514J.102.
27
(2)
“Health
care
professional”
means
the
same
as
defined
in
28
section
514J.102.
29
(3)
“Health
care
provider”
or
“provider”
means
a
health
care
30
professional
or
a
facility.
31
(4)
“Health
care
services”
means
the
same
as
defined
in
32
section
514J.102.
33
(5)
“Health
insurer”
means
an
entity
subject
to
the
34
insurance
laws
and
regulations
of
this
state,
or
subject
to
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the
jurisdiction
of
the
commissioner,
that
contracts
or
offers
1
to
contract
to
provide,
deliver,
arrange
for,
pay
for,
or
2
reimburse
any
of
the
costs
of
health
care
services,
including
3
an
insurance
company
offering
sickness
and
accident
plans
under
4
chapter
509,
514,
or
514A,
a
health
maintenance
organization,
5
a
nonprofit
health
service
corporation,
or
any
other
entity
6
providing
a
plan
of
health
insurance,
health
benefits,
or
7
health
services.
8
b.
A
health
care
provider
shall
have
up
to
three
hundred
9
sixty-five
calendar
days
after
the
date
of
provision
of
health
10
care
services
to
timely
submit
a
claim
to
a
health
insurer
for
11
the
health
care
services
provided
by
the
provider.
12
c.
A
health
care
provider
shall
have
up
to
three
hundred
13
sixty-five
calendar
days
from
the
date
of
last
adjudication
by
14
a
health
insurer
to
resubmit
a
claim
for
adjustment
of
a
paid
15
claim,
or
for
reconsideration
of
a
denied
claim.
16
d.
A
claim
submitted
by
a
health
care
provider
shall
not
be
17
paid
by
a
health
insurer
if
the
claim
is
received
by
the
health
18
insurer
two
or
more
years
from
the
date
of
provision
of
health
19
care
services
by
the
health
care
provider.
20
e.
This
subsection
shall
not
apply
to
Medicaid
providers
and
21
Medicaid
managed
care
organizations.
22
2.
a.
A
health
insurer
shall
either
accept
and
pay
a
clean
23
claim,
or
deny
a
clean
claim.
24
b.
For
purposes
of
this
subsection,
“clean
claim”
means
25
a
properly
completed
paper
or
electronic
billing
instrument
26
containing
all
reasonably
necessary
information
that
does
not
27
involve
coordination
of
benefits
for
third-party
liability,
28
preexisting
condition
investigations,
or
subrogation,
and
that
29
does
not
involve
the
existence
of
particular
circumstances
30
requiring
special
treatment
that
prevents
a
prompt
payment
from
31
being
made.
32
c.
The
commissioner
shall
adopt
rules
establishing
processes
33
for
timely
adjudication
and
payment
of
claims
by
health
34
insurers.
The
rules
shall
be
consistent
with
the
time
frames
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and
other
procedural
standards
for
claims
decisions
by
group
1
health
plans
established
by
the
United
States
department
of
2
labor
pursuant
to
29
C.F.R.
pt.
2560
in
effect
on
January
1,
3
2020.
4
d.
Payment
of
a
clean
claim
shall
include
interest
at
the
5
rate
of
ten
percent
per
annum
when
a
health
insurer,
or
an
6
entity
that
administers
or
processes
claims
on
behalf
of
the
7
health
insurer,
fails
to
timely
pay
a
claim.
8
e.
This
subsection
shall
not
apply
to
liability
insurance,
9
workers’
compensation
or
similar
insurance,
automobile
or
10
homeowners’
medical
payment
insurance,
disability
income,
or
11
long-term
care
insurance.
12
Sec.
4.
Section
507B.6,
subsection
1,
Code
2019,
is
amended
13
to
read
as
follows:
14
1.
Whenever
the
commissioner
believes
that
any
person
has
15
been
engaged
or
is
engaging
in
this
state
in
any
unfair
method
16
of
competition
or
any
unfair
or
deceptive
act
or
practice
17
whether
or
not
defined
in
section
507B.4
,
507B.4A
507B.04B
,
or
18
507B.5
and
that
a
proceeding
by
the
commissioner
in
respect
19
to
such
method
of
competition
or
unfair
or
deceptive
act
or
20
practice
would
be
in
the
public
interest,
the
commissioner
21
shall
issue
and
serve
upon
such
person
a
statement
of
the
22
charges
in
that
respect
and
a
notice
of
a
hearing
on
such
23
charges
to
be
held
at
a
time
and
place
fixed
in
the
notice,
24
which
shall
not
be
less
than
ten
days
after
the
date
of
the
25
service
of
such
notice.
26
Sec.
5.
Section
507B.12,
subsection
1,
Code
2019,
is
amended
27
to
read
as
follows:
28
1.
The
commissioner
may,
after
notice
and
hearing,
29
promulgate
reasonable
rules,
as
are
necessary
or
proper
to
30
identify
specific
methods
of
competition
or
acts
or
practices
31
which
are
prohibited
by
section
507B.4
,
507B.4A
507B.04B
,
or
32
507B.5
,
but
the
rules
shall
not
enlarge
upon
or
extend
the
33
provisions
of
such
sections.
Such
rules
shall
be
subject
to
34
review
in
accordance
with
chapter
17A
.
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504
Sec.
6.
Section
514F.6,
subsection
2,
paragraph
b,
Code
1
2019,
is
amended
to
read
as
follows:
2
b.
“Clean
claim”
means
the
same
as
defined
in
section
3
507B.4A
507B.04B
,
subsection
2
,
paragraph
“b”
.
4
EXPLANATION
5
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
6
the
explanation’s
substance
by
the
members
of
the
general
assembly.
7
This
bill
relates
to
the
timely
submission
of
claims
by
8
health
care
providers
to
health
insurers.
The
bill
defines
9
“health
insurer”,
“health
care
provider”,
and
“health
care
10
services”.
11
The
bill
provides
that
a
health
care
provider
shall
have
12
up
to
365
days
after
the
date
of
the
provision
of
health
care
13
services
to
submit
a
claim
to
a
health
insurer.
The
provider
14
has
up
to
365
days
from
the
date
of
the
last
adjudication
15
by
a
health
insurer
to
resubmit
a
claim
for
adjustment
or
16
reconsideration.
A
claim
submitted
two
or
more
years
from
the
17
date
of
provision
of
health
care
services
shall
not
be
paid
by
18
an
insurer.
These
provisions
of
the
bill
apply
to
all
health
19
insurers
and
health
care
providers
except
Medicaid
providers
20
and
Medicaid
managed
care
organizations.
21
The
bill
makes
conforming
changes.
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