Add Notes

State of South Dakota  
SEVENTY-SIXTH SESSION
LEGISLATIVE ASSEMBLY,  2001  

445E0642  
SENATE HEALTH AND HUMAN SERVICES COMMITTEE ENGROSSED   NO. SB 231   -   02/14/2001  
This bill has been extensively amended (hoghoused) and may no longer be consistent with the original intention of the sponsor.
        Introduced by: Senators Reedy, Dennert, Duxbury, Ham, Hutmacher, Koetzle, McIntyre, Moore, Sutton (Dan), Symens, and Volesky and Representatives Nesselhuf, Bartling, Bradford, Burg, Davis, Elliott, Flowers, Hanson (Gary), Hargens, Lange, Monroe, Nachtigal, Olson (Mel), Peterson (Jim), Sigdestad, and Van Norman  


         FOR AN ACT ENTITLED, An Act to  provide for the prompt payment of certain uncontested health care claims.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF SOUTH DAKOTA:
     Section  1.  That chapter 58-12 be amended by adding thereto a NEW SECTION to read as follows:
     As used in this Act, the term, clean claim, means a claim for payment of health care expenses that is submitted to a health carrier on the carrier's standard claim form with all required fields completed with correct and complete information in accordance with the carrier's published filing requirements. The term, clean claim, does not include a claim for payment of expenses incurred during a period of time for which premiums are delinquent, except to the extent otherwise required by law.
     Section  2.  That chapter 58-12 be amended by adding thereto a NEW SECTION to read as

follows:

     Every health carrier shall provide a copy of its filing requirements upon request to:
             (1)    Every enrollee or insured upon enrollment in the carrier's plan or upon issuance of the policy if applicable;
             (2)    Every enrollee or insured, upon request, within fifteen calendar days;
             (3)    Every participating provider upon acceptance of the provider into the carrier's network; and
             (4)    Every enrollee, insured, and participating provider within fifteen calendar days after any change in the standard form or the accompanying instructions or requirements if applicable.
     Section  3.  That chapter 58-12 be amended by adding thereto a NEW SECTION to read as follows:
     Each clean claim shall be paid to the person entitled thereto, denied, or settled within thirty calendar days after receipt by the carrier if submitted electronically and within forty-five calendar days after receipt by the carrier. If the resolution of an otherwise clean claim requires additional information, the carrier shall, within thirty calendar days after receipt of the claim, give the provider, policyholder, insured, or patient, as appropriate, a full explanation of what additional information is needed. The person receiving a request for additional information shall submit all additional information requested by the carrier within thirty calendar days after receipt of such request.
     Section  4.  That chapter 58-12 be amended by adding thereto a NEW SECTION to read as follows:
     Notwithstanding any provision of any indemnity or health policy or certificate to the contrary, if a provider fails to timely submit additional information requested under section 3 of

this Act, the health carrier may deny an otherwise clean claim or continue to process the claim beyond the time frames contained in section 3 of this Act.
     Section  5.  That chapter 58-12 be amended by adding thereto a NEW SECTION to read as follows:

     Absent suspected fraud, all clean claims, except those described in section 3 of this Act shall be paid, denied, or settled within ninety calendar days after receipt by the carrier.
     Section 5. That chapter 58-12 be amended by adding thereto a NEW SECTION to read as follows:
     This Act applies to any health insurer or health maintenance organization that issues health insurance coverage pursuant to chapters 58-17A, 58-17B, 58-17, 58-18, 58-18B, 58-19, 58- 37A, 58-38, 58-39, 58-40, and 58-41.