Prompt Payment of Clean Claims

Prompt Payment Standards

HMSA is committed to comply with prompt payment of Medicare Prescription Drug (Part D) clean claim requirements outlined by the Centers for Medicare & Medicaid Services (CMS). HMSA will issue, mail, or otherwise transmit payment on clean claims that meet the definition of a Covered Service as defined in the Pharmacy’s Participating Provider Agreement with HMSA and are submitted by providers other than long-term care pharmacies and mail order pharmacies participating in a Medicare-based contract, for example the HMSA 65C Plus contract, within the following time frames:

• 14 calendar days after receipt of claims submitted electronically. The date of receipt is the date on which the claim is transferred.
• 30 calendar days after receipt of claims submitted other than electronically. The date of receipt is the date specified in the time stamp of the transmission or on the fifth day after the postmark date of the claim, whichever is sooner.

Clean Claims Defined

A clean claim is defined as a claim that has no defect or impropriety (including any lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment from being made on the claim. A claim is also considered to be a clean claim if HMSA does not provide notice to the provider of any deficiency in the claim either thin 10 days after the claim is received electronically, or 15 days after the claim is received other than electronically. A determination that a claim is clean does not mean that the claim has been determined to be a Covered Service.

Claims That Do Not Meet Clean Claims Definition

For a claim that does not meet the definition of a clean claim, HMSA must notify the provider of any deficiency either within 7 days after the claim is received electronically, or 15 days after the claim is received other than electronically. Notification shall specify all defects or improprieties in the claim and indicate the additional information or documentation necessary for proper processing and payment of the claim.

Interest On Claims That Are Not Paid Within Clean Claims Time Frames

If the payment is not issued, mailed or otherwise transmitted within the applicable number of calendar days after the clean claim is received, HMSA shall pay interest to the provider at a rate equal to the weighted average of interest on 3-month marketable Treasury securities determined during that period, increased by 0.1 percentage point for the period beginning on the day after the required payment date and ending on the date on which payment is made.

This interest payment shall not apply where CMS determines that interest payments are not required, such as due to unique and unexpected circumstances that prevent the timely processing of claims.

Revision History