Washington Administrative Code
Title 284 - Insurance Commissioner, Office of the
Chapter 284-51 - Standards for coordination of benefits
Section 284-51-215 - Time limit
Current through Register Vol. 24-06, March 15, 2024
(1) Each issuer must establish time limits for payment of a claim and may not unreasonably delay payment through the application of a coordination of benefits provision. Time limits established by a primary plan must be no less favorable than those contained in WAC 284-170-431. Primary plans must pay ninety-five percent of clean claims subject to this chapter within thirty calendar days of receipt or of determining they are the primary plan, and must pay all clean claims subject to this chapter within sixty calendar days of receipt or of determining they are the primary plan. Any time limit established by a secondary plan that is in excess of thirty days from receipt of a claim, with the primary plan's explanation of benefit information or other primary payment details needed to process the claim, will be considered unreasonable. The deadlines established in this subsection may be extended for the length of time a primary or secondary plan must wait for information needed from the provider (e.g., medical records) or from the enrollee (e.g., motor vehicle accident information), in order to adjudicate the claim.
(2) The specific time limits for coordination of benefits processing include:
(3) When payment is necessarily delayed for reasons other than the application of a coordination of benefits provision, investigation of other plan coverage must be conducted concurrently to avoid delay in the ultimate payment of benefits. Any issuer that is required by the time limit in subsection (2) of this section to make payment as the primary plan may exercise its rights under its "right of recovery" provision for recovery of any excess payments. After payment information is received from the primary plan, the secondary plan may recover any excess amount paid under its "right of recovery" provision.
(4) The provisions in this section do not apply when medicare is the primary payer; in such cases federal medicare law governs.
Statutory Authority: RCW 48.02.060, 48.21.200, 48.44.050, and 48.46.200. 09-16-073 (Matter No. R 2008-20), § 284-51-215, filed 7/30/09, effective 9/1/09; 07-13-008 (Matter No. R 2005-07), § 284-51-215, filed 6/8/07, effective 7/9/07.