The Oklahoma Insurance Department is committed to assuring the prompt processing and payment of healthcare “clean” claims. Oklahoma’s Prompt Pay law establishes strict time frames for the processing and payment of such claims to providers of health care services. We encourage all health care providers who have claims that have not been paid after forty-five (45) days of submittal to an insurer to review the information below.
Providers and facilities may discuss concerns with the Consumer Assistance Division in advance of filing a written complaint, by calling 1-800-522-0071 or (405) 521-2991. However, a written complaint will be required in order for the Division to initiate a formal review or inquiry. We are more than happy talk with you and assist you with determining whether filing a complaint is an appropriate course of action as well as assisting you with identifying potential alternative courses of action.
What is Oklahoma’s Prompt-Pay law?
Oklahoma’s Prompt-Pay law, 36 O.S. § 1219, requires the following: In the administration, servicing, or processing of any accident and health insurance policy, every insurer shall reimburse all clean claims of an insured, an assignee of the insured, or a health care provider within forty-five (45) calendar days after receipt of the claim by the insurer.
What is a “clean claim?”
Pursuant to 36 O.S. § 1219 (B)(2), a clean claim is a claim that has no defect or impropriety, including a lack of any required substantiating documentation, or particular circumstance requiring special treatment that impedes prompt payment.
What if the claim is not a “clean claim?”
Pursuant to 36 O.S. § 1219 (C), if the claim, or any part of it, is not a “clean claim,” the insurer must notify the insured or their assignee and the health care provider in writing with 30 calendar days after receipt of the claim. That notice must specify the portion of the claim that is causing the delay and explain any additional information or corrections needed.
Where can I file a complaint against a health plan insurer for not paying the claim?
Please note: A form must be submitted for each individual unpaid claim.
Who can file a prompt payment grievance?
Medical providers including health care professionals or health care facilities may file a complaint for late payment of a claim. As a provider, you must allow the health plan forty-five 45 days after submission of a clean claim to pay the claim before you can file a complaint.
What information is needed when a provider complaint is filed?
Including as much relevant information as possible with your complaint can help speed the Department’s review. The following information may be needed:
- The name of the insurance company involved.
- A written statement outlining your complaint and summarizing the facts. Provide copies of correspondence between you and the carrier and other written documentation that may help state your case.
- If applicable, the type of benefit plan involved (i.e., PPO, HMO, indemnity) and specific benefit plan name if it is known (e.g., OK HMO’s “Freedom Plan”)
- If applicable, the name of the employer through which insurance coverage is provided
- Provider PIN such as health plan/companyID/tax ID
- Member ID number
- Date of original claim filing
- Date of service
- Billed amount for the service
- Description of the service or CPT code involved.
Not every complaint will require every item listed above, but the more specifics that you provide with your initial complaint, the quicker we can evaluate it and take action.
If I have performed a service for a Medicaid patient, can I use this grievance process to get that claim paid?
No, all complaints regarding Medicaid must be submitted to the Oklahoma Health Care Authority (OHCA). The OHCA may be contacted at the following number (405) 522-7300.
Does the Oklahoma Insurance Department have the authority to investigate all provider complaints against health insurers?
Yes. As a regulatory agency, the Oklahoma Insurance Department’s authority to act on complaints is defined by the laws that it is charged to enforce. Therefore, complaints from consumers and health care providers are analyzed carefully to determine what (if any) action is appropriate. The following considerations may influence our approach in handling a complaint.
- Does the complaint relate to any insurance law or regulation? If so, is it a state or federal law or regulation?
- Does the complaint relate to the possible failure of an insurer to fulfill the terms of the health insurance policy it sold to the employer, employee, or individual?
- Does the complaint provide information or does the Department have additional information from other sources to indicate a general business practice of the insurer?
- Are there other circumstances specific to the case that need to be considered?
Please note: The Insurance Department does not have broad authority to enforce all provisions of provider contracts; however, issues relating to regulatory concerns can be investigated.
What happens if a clean claim is not promptly paid?
Pursuant to 36 O.S. § 1219(F), (G), an overdue payment shall bear simple interest at the rate of 10% per year. If litigation is brought, the prevailing party is entitled to recover a reasonable attorney fee.
What health plans are subject to the prompt payment procedures?
Most health insurance companies, Medicare supplement insurers, long-term care insurance companies, multiple employer welfare arrangements (MEWAs), health maintenance organizations (HMOs), and non-profit health care corporations are subject to Oklahoma’s prompt-pay law.
What health plans may not be subject to the prompt payment procedures?
Certain complaints do not fall within the jurisdiction of the Insurance Department and must therefore be referred elsewhere. However; we urge you to begin your Prompt-Pay grievance process with the Insurance Department.
The following are health insurance programs for which the Insurance Department does not have regulatory authority:
- State Employee Health Plans (Health Choice).
- Self-Funded Employee Health Benefit Plans
– Complainants are referred to the plan administrator, the employer’s human resources department, and/or the U.S. Department of Labor. Please click here for additional information regarding ERISA plans
- Federal Employees’ Health Plan – Complainants are referred to the U.S. Office of Personnel Management.
- Medicare (“traditional Medicare”) – Complainants will be referred to the Center for Medicare and Medicaid Services (CMS). Complaints regarding other Medicare options such as Medicare Advantage or Part-D plans will be reviewed by the Department to determine whether they fall under the jurisdiction of the Department of Insurance, CMS or both.
- Medicaid – Complainants will be referred to the Oklahoma Health Care Authority.
- Medical Malpractice or Risk Management Issues – Complainants are referred to their malpractice insurer.
- Legal/Contract Issues – Complainants with issues related to contract enforcement, fraud and abuse and other similar issues may be instructed to consult with their legal counsel.