Everyone knows claims made to healthcare insurance companies can take a long time to actually materialize into payment—which can create a big financial burden in the time between when you need the money you are owed and when you actually receive it. Florida statute 627.6131, otherwise known as the “Prompt Pay Statute,” requires insurance companies to make decisions and pay out on claims quickly.
The timeframe created by this legislation depends on how the claim was received, either electronically or physically. Claims from most medical providers will most likely be submitted electronically to reduce paperwork, lower the risk of important documents getting lost, and assist with organization. Odds are this is what will apply for your claim.
Electronic Claim Deadlines
When the claim is submitted electronically, the insurance provider has a few key deadlines they must legally follow. The most important deadline is 90 days, which is the amount of time your insurance company has to either accept and pay or deny your claim once they receive it. This is important because it gives them a hard deadline which they must stick to for the entire process.
The first smaller deadline is that your insurance company must acknowledge receipt of your claim within 24 hours of the beginning of the next business day. The insurance company then has 20 days to either accept and pay your claim or notify your medical provider that they are either denying or contesting it, plus provide a detailed list of reasons why. If any additional information is requested, your medical provider has 35 days to submit it to the insurance company.
Upon the receipt of this additional info, your insurance company may then has up to the 90-day process limit. In other words, say each party took their legally-defined maximum to complete each step of the process. That’s one day to acknowledge the claim, 20 days to request more information, and 35 days to get the requested information back from the care provider, meaning 56 days will have already passed. Therefore, the insurance provider has only 34 days remaining to either pay or deny the claim.
There is one more important deadline consumers should know: if your insurance company has not denied or paid your claim within 120 days of receiving it, then they become obligated to pay your claim by Florida law, and they lose their legal right to contest it.
Non-Electronic Claim Deadlines
While the process for non-electronic claim submissions is exactly the same, Florida law allows each step a few additional days due to travel times for paperwork and mail service processing. Acknowledgment of the initial claim must be made within 15 days of its receipt by your insurance provider. They then have 40 days to pay or contest the claim, and your medical provider must provide any additional requested information within the same 35 day period. In total, your insurance provider has 120 days to pay or deny your claim after they receive it via non-electronic means. If the claim goes beyond 140 days, they become legally obligated to pay it.
How does this affect me?
These deadlines are important to you as a policy holder because insurance companies will often times use stalling tactics to attempt to get off the hook for paying for certain claim expenses. If outstanding balances have not been paid after a certain period, medical providers may choose to assume the claim has been denied and will then pass the bill on to you. These bills can place a significant financial burden on you or your loved ones. When this is the case, knowing these laws can possibly help you fight back against your insurance company and get you the coverage you deserve.
If you feel as though you have been mistreated by your medical insurance company, or that your claim was unreasonably mishandled or denied, a Tampa insurance law attorney may be able to help. Danahy & Murray, P.A. is a dedicated team of knowledgeable legal professionals that has helped clients recover a total of over $100 million in legally entitled benefits from mishandled claims.