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Prompt Pay Regulations – Frequently Asked Questions


How can I obtain a copy of the Prompt Pay Regulations?
Click here for N.J.A.C. 11:22, 1.1 et seq., effective January 2, 2001.

What is the purpose of the Prompt Pay Regulations?
The regulations set the standard for the payment of clean claims related to health benefit plans and dental plans.

To which health insurance carriers do the regulations apply?
The Prompt Pay regulations apply to carriers authorized to issue health benefit or dental plans in New Jersey, i.e., a benefits plan which pays hospital and medical expense benefits and is delivered or issued for delivery in New Jersey.

What health insurance carriers are not covered by these regulations?
The Prompt Pay regulations do not apply to Medicare, Workers Compensation, CHAMPUS, State Health Benefits, disability, automobile medical payment insurance, personal injury protection insurance (PIP), self-insurance, or Federal Employee Plans.

Are all claims covered by these regulations?
No. The regulations apply to the payment of "clean" claims only (N.J.A.C. 11:22-1.2).

What is a "clean" claim?

  • The claim must be for a covered insured; must be for a covered service; the claim must contain all the correct information needed by the carrier to process the claim; the claim does not require special treatment.
  • Carriers may change the information and documentation they require as long as participating providers are given 30 days notice of the change (N.J.A.C. 11:22-1.4).

Is the insurance carrier supposed to let me know the claim was received?
Claims should be acknowledged by the carrier within 2 working days of an electronic submission or 15 working days after receipt of written notice. (Please note, however, that claims containing the type of errors that interfere with the successful transmission to a carrier may not reach the carrier, and therefore may not be acknowledged.)

How can I check if my claim was received by the carrier?
Acknowledgment of receipt of an electronic claim shall go to the entity, i.e. the provider or clearinghouse etc., from which the carrier received the claim (N.J.A.C. 11:22-1.3).

  • If the carrier offers web-based access to claims status, the information should include the date of receipt. This constitutes acknowledgement of the claim if posted within 2 days after receipt of electronic submission or 15 days after receipt of written notice.

When does a “clean” claim have to be paid?
“Clean” claims must be paid or denied within 30 calendar days after receipt of a claim submitted electronically, or within 40 calendar days after receipt for claims submitted by other than electronic means (N.J.A.C. 11:22-1.5).

What happens if part of the claim is disputed or denied?
Carriers shall pay claims that are disputed or denied because of missing information or documentation within 30 calendar days (electronically submitted claims) or 40 calendar days of receipt of the missing information or documentation.

If only a portion of the claim is denied or disputed , the carrier shall remit payment for the uncontested portion within the above timeframes (N.J.A.C. 11:22-1.6).

Is there compensation if the insurance carrier does not pay a clean claim on time?
A carrier that does not pay a clean claim within 30 or 40 calendar days after receipt of all the required information must include late interest at the rate of 10% per year (N.J.A.C. 11:22-1.6(c)).

What recourse do I have under the regulations if I do not agree with the insurance carrier?
Carriers must provide prompt payment internal and external appeal mechanisms to participating health care providers (N.J.A.C. 11:22-1.8). (You may also have additional remedies under contract law that you may wish to discuss with your attorney; utilization of the internal and external appeal mechanisms provided pursuant to the Prompt Pay regulations should not require that you waive other remedies at law that may be available to you.)

Internal payment appeals must be conducted and the results communicated in a written decision to the participating provider within ten (10) business days after the carrier receives the appeal.

  • The written decision must contain the names, titles and credentials of the persons participating in the review.
  • The written decision must have a statement of the provider's grievance.
  • The written decision must have a description of the evidence or documentation that supports the carrier's decision.
  • If the carrier's decision is adverse, the written decision must contain a description of the method that a provider can use to obtain an external review – Alternate Dispute Resolution (ADR).

What happens if I do not agree with the results of an internal payment appeal?
Every carrier must offer an independent, external ADR mechanism to participating health care providers to review adverse decisions of internal appeals. (You may also have additional remedies under contract law that you may wish to discuss with your attorney.)

  • ADR is through an independent party with the costs borne equally by the parties.
  • The decision is non-binding unless the parties agree otherwise.
Updated: November 29, 2005

 
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