Hawaii Administrative Rules
Title 17 - DEPARTMENT OF HUMAN SERVICES
Department of Human Services
Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES
Section 17-1739.1-15 - Timely claims payment

Universal Citation: HI Admin Rules 17-1739.1-15

Current through November, 2024

(a) The department shall pay ninety per cent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within thirty days, and ninety-nine per cent of the clean claims within ninety days of the date of receipt.

(b) The department shall pay all other claims within twelve months of the date of receipt, except where:

(1) Retroactive adjustments are paid to providers who are reimbursed under a retrospective payment system;

(2) Claims are from providers under investigation for fraud or abuse; or

(3) Payments are made in accordance with a court order, hearing decision, corrective action, or to extend benefits of these actions to others in the same situation as those directly affected.

(c) Prepayment and post-payment claims review shall be conducted for all claims to verify:

(1) Eligibility and proper authorization of service;

(2) The number of visits and services for consistency with age, sex, and illness;

(3) That payment does not exceed reimbursement rates or limits; and

(4) Third party liability, if any.

(d) Post-payment claims review shall meet the requirements dealing with fraud and utilization control.

(e) The department shall provide any reports and documentation in compliance with this chapter and any conditions that the federal Centers for Medicare and Medicaid Services may require.

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