Current through Reg. 50, No. 13; March 28, 2025
(a) An MCC must
submit to the department quarterly claims payment and related penalty and
interest payment information, and information regarding complaints, in
compliance with the requirements of this section.
(b) The MCC must submit the report required
by subsection (a) of this section to the department on or before:
(1) May 15th for the months of January,
February, and March of each year;
(2) August 15th for the months of April, May,
and June of each year;
(3) November
15th for the months of July, August, and September of each year; and
(4) February 15th for the months of October,
November, and December of each preceding calendar year.
(c) The report required by subsection (a) of
this section must include, at a minimum, the following information:
(1) number of claims received from
noninstitutional preferred providers;
(2) number of claims received from
institutional preferred providers;
(3) number of clean claims received from
noninstitutional preferred providers;
(4) number of clean claims received from
institutional preferred providers;
(5) number of clean claims from
noninstitutional preferred providers paid within the applicable statutory
claims payment period;
(6) number
of clean claims from noninstitutional preferred providers paid on or before the
45th day after the end of the applicable statutory claims payment
period;
(7) number of clean claims
from institutional preferred providers paid on or before the 45th day after the
end of the applicable statutory claims payment period;
(8) number of clean claims from
noninstitutional preferred providers paid on or after the 46th day and before
the 91st day after the end of the applicable statutory claims payment
period;
(9) number of clean claims
from institutional preferred providers paid on or after the 46th day and before
the 91st day after the end of the applicable statutory claims payment
period;
(10) number of clean claims
from noninstitutional preferred providers paid on or after the 91st day after
the end of the applicable statutory claims payment period;
(11) number of clean claims from
institutional preferred providers paid on or after the 91st day after the end
of the applicable statutory claims payment period;
(12) number of clean claims from
institutional preferred providers paid within the applicable statutory claims
payment period;
(13) number of
claims paid under the provisions of §
21.2809 of this title (relating to
Audit Procedures);
(14) number of
requests for verification received under §
19.1719 of this title (relating to
Verification for Health Maintenance Organizations and Preferred Provider
Benefit Plans);
(15) number of
verifications issued under §
19.1719 of this title;
(16) number of declinations of requests for
verifications under §
19.1719 of this title;
(17) number of certifications of catastrophic
events sent to the department;
(18)
number of calendar days business was interrupted for each corresponding
catastrophic event;
(19) number of
electronically submitted, affirmatively adjudicated pharmacy claims received by
the MCC;
(20) number of
electronically submitted, affirmatively adjudicated pharmacy claims paid within
the 18-day statutory claims payment period;
(21) number of electronically submitted,
affirmatively adjudicated pharmacy claims paid on or before the 45th day after
the end of the 18-day statutory claims payment period;
(22) number of electronically submitted,
affirmatively adjudicated pharmacy claims paid on or after the 46th day and
before the 91st day after the end of the 18-day statutory claims payment
period; and
(23) number of
electronically submitted, affirmatively adjudicated pharmacy claims paid on or
after the 91st day after the end of the 18-day statutory claims payment
period.
(d) An MCC must
annually submit to the department, on or before August 15th, at a minimum,
information related to the number of declinations of requests for verifications
from July 1st of the prior year to June 30th of the current year, in the
following categories:
(1) policy or contract
limitations:
(A) premium payment time frames
that prevent verifying eligibility for a 30-day period;
(B) policy deductible, specific benefit
limitations, or annual benefit maximum;
(D) no coverage or change in membership
eligibility, including individuals not eligible, not yet effective, or for whom
membership is canceled;
(E)
preexisting condition limitations; and
(2) declinations due to an inability to
obtain necessary information to verify requested services from the following
persons:
(A) the requesting physician or
provider;
(B) any other physician
or provider; and
(e)
In addition to the information reported under subsection (c) of this section,
the report required by subsection (a) of this section must also include, at a
minimum, the following information:
(1) the
total dollar amount of the claims described in each of the following
subparagraphs:
(A) clean claims from
noninstitutional preferred providers paid on or before the 45th day after the
end of the applicable statutory claims payment period;
(B) clean claims from institutional preferred
providers paid on or before the 45th day after the end of the applicable
statutory claims payment period;
(C) clean claims from noninstitutional
preferred providers paid on or after the 46th day and before the 91st day after
the end of the applicable statutory claims payment period;
(D) clean claims from institutional preferred
providers paid on or after the 46th day and before the 91st day after the end
of the applicable statutory claims payment period;
(E) clean claims from noninstitutional
preferred providers paid on or after the 91st day after the end of the
applicable statutory claims payment period; and
(F) clean claims from institutional preferred
providers paid on or after the 91st day after the end of the applicable
statutory claims payment period;
(2) the dollar amount that the MCC paid late
to an institutional preferred provider for each clean claim that the MCC paid
to the institutional preferred provider:
(A)
on or before the 45th day after the end of the applicable statutory claims
payment period;
(B) on or after the
46th day and before the 91st day after the end of the applicable statutory
claims payment period; and
(C) on
or after the 91st day after the end of the applicable statutory claims payment
period;
(3) the dollar
amount that the MCC paid late to a noninstitutional preferred provider for each
clean claim that the MCC paid to the noninstitutional preferred provider:
(A) on or before the 45th day after the end
of the applicable statutory claims payment period;
(B) on or after the 46th day and before the
91st day after the end of the applicable statutory claims payment period;
and
(C) on or after the 91st day
after the end of the applicable statutory claims payment period:
(4) the amount of interest, based
on the penalty dollar amount, that the MCC paid to the department for each
clean claim that the MCC paid to a noninstitutional preferred provider on or
after the 91st day after the end of the applicable statutory claims payment
period;
(5) for each clean claim,
the associated penalty dollar amount as reported under subsection (e),
paragraphs (2) and (3) of this section; and
(6) the total number of written complaints
received by the MCC for failure to pay a clean claim on timey.
(f) The claim-level data required
by subsections (e)(2) - (e)(5) must be reported using a unique identifier for
each claim, created and maintained solely by the MCC, that is not the claim
number. The unique identifier must consist of no more than 15 characters and
may not contain any of the identifiers listed in
45
C.F.R. §
164.514(b).
The MCC must relate the unique identifier back to the claim on request by the
department during an examination.
(g) The quarterly report required in
subsection (a) of this section must be submitted electronically as specified on
the department's website.
(h)
Subsections (e), (f), and (g) of this section apply to reports submitted under
subsection (a) of this section beginning with the report required to be
submitted by May 15, 2022, for the months of January, February, and March of
that year.
