Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-215 - Time limit

Current through Register Vol. 24-14, July 15, 2024
(1) Each issuer
			 must establish time limits for payment of a claim and may not unreasonably
			 delay payment through the application of a coordination of benefits provision.
			 Time limits established by a primary plan must be no less favorable than those
			 contained in WAC
			 284-170-431. Primary plans must
			 pay ninety-five percent of clean claims subject to this chapter within thirty
			 calendar days of receipt or of determining they are the primary plan, and must
			 pay all clean claims subject to this chapter within sixty calendar days of
			 receipt or of determining they are the primary plan. Any time limit established
			 by a secondary plan that is in excess of thirty days from receipt of a claim,
			 with the primary plan's explanation of benefit information or other primary
			 payment details needed to process the claim, will be considered unreasonable.
			 The deadlines established in this subsection may be extended for the length of
			 time a primary or secondary plan must wait for information needed from the
			 provider (e.g., medical records) or from the enrollee (e.g., motor vehicle
			 accident information), in order to adjudicate the claim.
(2) The specific time limits for coordination
			 of benefits processing include:
(a) When an
			 issuer has been notified that more than one plan covers an enrollee who has
			 submitted a claim, the issuer shall resolve with the other plan in not more
			 than thirty calendar days which plan is primary. This deadline may be extended
			 in situations involving court orders for dependent coverage, if the court order
			 contains information needed to determine which plan is primary and has not been
			 provided to the issuer. If agreement cannot be reached, both plans shall pay as
			 set forth in WAC
			 284-51-205(4)(f).
(b) Once the primary plan and secondary plan
			 have been established, if the secondary plan receives a claim without the
			 primary plan's explanation of benefit information or other primary payment
			 details needed to process the claim, including at least the paid amount and the
			 allowed amount, the secondary plan will notify the submitting provider and/or
			 enrollee as soon as possible and within thirty calendar days of receipt of the
			 claim, that the secondary claim is incomplete without such primary plan
			 information. The secondary plan will promptly process the claim after it has
			 been resubmitted with the explanation of benefit information from the primary
			 payer.
(c) If a primary plan has
			 not adjudicated a claim within sixty calendar days of receipt of the claim and
			 all supporting documentation, and if the primary plan is not waiting for
			 information from the provider (e.g., medical records) or from the enrollee
			 (e.g., motor vehicle accident information), needed to adjudicate the claim, the
			 provider or enrollee may submit the claim and notice of the primary plan's
			 failure to pay to the secondary plan which shall pay the provider's claim as
			 primary within thirty calendar days.