This excerpt taken from the CNC 10-K filed Feb 24, 2006.
188.8.131.52 Claims Processing Requirements
The HMO must process all provider claims and must pay all claims for Medically Necessary Covered Services that are filed within the time frames specified by this Section.
The HMO must administer an effective, accurate, and efficient claims payment process in compliance with state and federal laws, rules and regulations, the Contract, and the Uniform Managed Care Manual, which includes claims processing procedures.
The HMO must maintain a claim retrieval service processing system that can identify date of receipt, action taken on all provider claims or Encounters (i.e., paid, denied, pended, appealed, other), and when any action was taken in real time.
All provider claims that are clean and payable must be paid within 30 days from the date of claim receipt.
The HMO must offer its Providers/subcontractors the option of submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims. EDI processing must be offered as an alternative to the filing of paper claims. Electronic claims must use HIPAA-compliant electronic formats.
The HMO is subject to remedies, including liquidated damages, if within 30 days of receipt, the HMO does not process and finalize to a paid or denied status 98% of all Clean Claims. The HMO is subject to remedies, including liquidated damages, if within 90 days of receipt, the HMO does not process and finalize to a paid or denied status 99% of all Clean Claims.
The HMO is subject to remedies, including liquidated damages, if the HMO does not pay providers interest at an 18 % annual rate, calculated daily for the full period in which the Clean Claim remain unadjudicated beyond the 30-day claims processing deadline. The HMO may negotiate Provider contract terms that indicate that duplicate claims filed prior to the expiration of 31 days would not be subject to the 18 % interest payment if not processed within 30 days.
The HMO must not pay any claim submitted by a provider excluded or suspended from the Medicare, Medicaid, or CHIP programs for Fraud, Abuse, or Waste. The HMO must not pay any claim submitted by a Provider that is on payment hold under the authority of HHSC or its authorized agent(s), or who has pending accounts receivable with HHSC.