Prompt Payment for Health Care and Health Insurance Benefits

(a)This Section applies to Health Plan Administrators, as defined by this Article, organized and operating under the laws of Guam.

(b)Health Plan Administrators shall reimburse a Clean Claim, or any portion thereof, submitted by a patient or Health Care Provider, that is eligible for payment and not contested or denied not more than fortyfive

(45)calendar days after receiving the Clean Claim filed in writing.

(c)If a claim is contested or denied, or requires more time for review by the Health Plan Administrator, the Health Plan Administrator shall notify the Health Care Provider in writing not more than thirty

(30)calendar days after receiving a claim filed for payment. The notice shall identify the contested or denied portion of the claim and the specific reason for contesting or denying the claim, and may request additional information. Requests for information on a contested or denied claim, or portion thereof, shall be reasonable and relevant to the determination of why the claim is being contested or denied. In no event may a claim be contested or denied for the lack of information that has no factual impact upon the Health Plan Administrator’s ability to adjudicate the claim.

(d)If information received pursuant to a request for additional information is satisfactory to warrant paying the Clean Claim, the Clean Claim shall be paid not more than forty-five

(45)calendar days after receiving the additional information in writing.

(e)The payment of a Clean Claim under this Section shall be effective upon the date of postmark of the mailing.

(f)Health Care Providers shall be responsible for obtaining proof in writing that a specific claim was delivered to a Health Plan Administrator on a specific date for determining the time periods for the purposes of prompt payment.

(g)Notwithstanding any provisions to the contrary, interest shall be allowed to accrue at a rate of 12% per annum as damages for money owed by a Health Plan Administrator for payment of a Clean Claim, or portion thereof, that exceeds the applicable reimbursement time limitations under this Section, including applicable costs for collecting past due payments as provided in § 9905 of this Article, as follows:

(1)for an uncontested Clean Claim:

(A)filed in writing, interest from the first calendar day after the forty-five

(45)day period in § 9902(b); or

(2)for a contested claim, or portion thereof, filed in writing:

(A)for which notice was provided under § 9902(c), interest from the first calendar day fortyfive

(45)days after the date the additional information is received; or CH. 9 CONSUMER HEALTH PROTECTION ACT

(B)for which notice was not provided, but not within the time specified under § 9902(c), interest from the first calendar day after the claim is received.

(h)Each Health Care Provider shall notify the Health Plan Administrator and patient in writing of all claims for which they intend to charge interest. Any interest that accrues as a result of the delayed payment of a Clean Claim, or any portion thereof, in accordance with the provisions of this Article shall be automatically added by the Health Plan Administrator to the amount of the unpaid Clean Claims due the Health Care Provider.

(i)Interest shall only apply to the principal portion of the claim.

(j)The provisions of this Section shall not apply to the payment or reimbursement of any claim, or portion thereof, involving a Coordination of Benefits between multiple payers of a claim.