PA Clean Claims Act

• The status of the claim
• Ensure that sufficient documentation supporting the claim has been provided
• Determine whether the claim is considered by the insurer or plan to be a clean claim

Once you have established that the claim is indeed a clean claim and the company is still delaying payment, the Insurance Department will be happy to assist you. In order to avoid further delay, it is recommended that you include the following information for each clean claim complaint submitted to the Insurance Department:

• Name of Provider
• Provider's Address
• Provider's Telephone Number
• Claim Number
• Insurance Company or Plan Name
• Insurance Company or Plan Address
• Name of Patient
• Employer Name
• Date of Service
• Date of Claim Filed with insurer or managed care plan
• Copy of explanation of benefits from the company or plan if available
• Copy of any other relative correspondence from the insurance company or managed care plan and explanations to assist in the Department's review.

Important Points to Remember:

• Claims with pertinent, outstanding information required for determining coverage or liability are not considered clean claims.
• The provision for prompt payment of clean claims is effective for services rendered on or after January 1, 1999.
• Act 68 provides for prompt payment of clean claims within 45 days of receipt of the claim. Please allow five days for receipt by the insurer from the date of mailing.
• The 45-day period for payment of a claim does not start until all the necessary documentation to process the claim has been provided to the insurance company or managed care plan.
• Healthcare providers, as defined in Act 68, are any licensed hospital, healthcare facility, medical equipment supplier or person who is licensed, certified, or otherwise regulated under the laws of Pennsylvania to provide healthcare services, including a physician, podiatrist, optometrist, psychologist, physical therapist, certified nurse practitioner, registered nurse, nurse midwife, physicians assistant, chiropractor, dentist, pharmacist, or an individual accredited or certified to provide behavioral health services.

If an insurer or managed care plan fails to remit the payment, a penalty interest at 10 percent per annum shall be added to the amount owed on the claim (see examples below). Interest shall be calculated beginning the day after the required payment date, 46 days after the claim became a clean claim and ending on the date the claim is paid. Interest calculated as less than two dollars would not be required for payment. The Insurance Department believes that a claim is considered "paid" on either the date a check is issued by the insurance company or an electronic transfer of funds from the insurance company tot he healthcare provider occurs.

Here are two examples for calculating a penalty interest for a delayed clean claim reflective of the following pertinent information:

Claim Amount Due: $500.00, Interest Penalty = 10% (.10)
(.10 x $500) = $50.00 (full year interest), ($50/365) = $0.14 (Daily Interest Penalty)

Example #1: Days delayed = 60
($0.14 x 60) = $8.40 (interest penalty due)
Total Payment Due = $508.40

Example #2: Days Delayed = 10
($0.14 x 10) = $1.40 (interest penalty due)
Total Payment Due = $500.00

Because the interest penalty due in Example 2 is less than $2.00, the insurance company or managed care plan is not required to pay the interest penalty amount.

If additional questions exist or further assistance is needed, please contact the Pennsylvania Insurance Department:

Insurance Department
Bureau of Consumer Services
Room 1321 Strawberry Square
Third and Walnut Streets
Harrisburg, PA 17120
(717) 787- 2317
http://www.insurance.state.pa.us/

State Government Links

PA Clean Claims Act

Political Action Committee

Continuity of Care Bill

House Version
Senate Version

Vote Smart