Report Title:

Health Insurance; Reimbursement

 

Description:

Adds definition of "clean claim" to law governing reimbursement for health insurance benefits.

 

HOUSE OF REPRESENTATIVES

H.B. NO.

202

TWENTY-FIRST LEGISLATURE, 2001

 

STATE OF HAWAII

 


 

A BILL FOR AN ACT

 

relating to health insurance.

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

SECTION 1. Chapter 431, Hawaii Revised Statutes, is amended by adding a new section to article 13 to be appropriately designated and to read as follows:

"§431:13-    Clean claim. A clean claim, as defined in section 431:13-108(i), shall not be contested, pending additional information requested by the insurer."

SECTION 2. Section 431:13-108, Hawaii Revised Statutes, is amended by amending subsection (i) to read as follows:

"(i) As used in this section:

"Claim" means any claim, bill, or request for payment for all or any portion of health care services provided by a health care provider of services submitted by an individual or pursuant to a contract or agreement with an entity.

"Clean claim" means a claim where the information adequately shows evidence that:

(1) The insured is covered by the claimed policy for the type of services received;

(2) The individual is the actual individual receiving the benefits;

(3) The physician is qualified to provide the services under Hawaii law; and

(4) The policy covers the type of services provided.

"Contest", "contesting", or "contested" means the circumstances under which an entity was not provided with, or did not have reasonable access to, sufficient information needed to determine payment liability or basis for payment of the claim.

"Deny", "denying", or "denied" means the assertion by an entity that it has no liability to pay a claim based upon eligibility of the patient, coverage of a service, medical necessity of a service, liability of another payer, or other grounds.

"Entity" means accident and sickness insurance providers under part I of article 10A of chapter 431, mutual benefit societies under article 1 of chapter 432, dental service corporations under chapter 423, and health maintenance organizations under chapter 432D.

"Health care facility" shall have the same meaning as in section 327D-2.

"Health care provider" means a Hawaii health care facility, physician, nurse, or any other provider of health care services covered by an entity."

SECTION 3. Act 99, Session Laws of Hawaii 1999, is amended by amending section 5 to read as follows:

"SECTION 5. This Act shall take effect on July 1, 2000[, and shall be repealed on July 1, 2002; provided that section 478-8(b), Hawaii Revised Statutes, shall be reenacted in the form in which it read on June 30, 2000]."

SECTION 4. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 5. This Act shall take effect upon its approval.

INTRODUCED BY:

_____________________________