For the purpose of this Chapter, the following words and phrases have the meanings assigned to them, respectively, except where the context otherwise requires:
(a) >Claim= means any claim, bill, or request for payment for all or any portion of healthcare services provided by a healthcare provider, or services submitted by an individual pursuant to a contract or agreement with a payer entity.a patient or Health Care Provider that is eligible for reimbursement.
(b) >Clean Claim= means a claim, or portion thereof, that may be processed without a reasonable request for additional information from the provider of service or from a third party, but does not include any claim under investigation for fraud or abuse or claims under review for medical necessity. In no event may a claim be contested or denied for the lack of information that has no factual impact upon the Health Plan Administrator=s ability to adjudicate the claim.
(c) >Contest,= >contesting= or >contested= means the circumstances under which a payer entity was not provided with, or did not have reasonable access to, sufficient pertinent information needed to determine payment liability or basis for payment of the claims.
(d) >Deny,= >denying= or >denied= means the assertion by a Health Plan Administrator that it has no, or partial, 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.

(e) >Health Plan Administrator= means insurance companies, health plan providers, all companies defined as third party payers, including, but not limited to, health maintenance organizations, medical service organizations, governmental organizations, worker=s compensation organization, or other legal entities providing or applying to provide third

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party payment or health insurance or payment for healthcare services that are organized and operating under the laws of Guam.
(f) >Health Care Provider= means any health care facility, hospital, clinic, laboratory, nursing home, home health agency, pharmacy, physician, dentist, nurse, acupuncturist, chiropractor, or any other practitioner or organized entity certified or licensed to provide health care services on Guam.

§ 9902. Prompt Payment for Health Care and Health Insurance
Benefits.

(a) This Section applies to Health Plan Administrators, as defined by this Chapter, organized and operating under the laws of Guam.

(b) Health Plan Administrators shall reimburse a Clean Claim, or any portion thereof, submitted by a patient or Health Care Provider, that is eligible for payment and not contested or denied not more than 45 calendar days after receiving the Clean Claim filed in writing.

(c) If a claim is contested or denied, or requires more time for review by the Health Plan Administrator, the Health Plan Administrator shall notify the Health Care Provider in writing not more than thirty (30) calendar days after receiving a claim filed for payment. The notice shall identify the contested or denied portion of the claim and the specific reason for contesting or denying the claim, and may request additional information. Requests for information on a contested or denied claim, or portion thereof, shall be reasonable and relevant to the determination of why the claim is being contested or denied. In no event may a claim be contested or denied for the lack of information that has no factual impact upon the Health Plan Administrator=s ability to adjudicate the claim.

(d) If information received pursuant to a request for additional information is satisfactory to warrant paying the Clean Claim, the Clean Claim shall be paid not more than 45 calendar days after receiving the additional information in writing.

(e) The payment of a Clean Claim under this Section shall be effective upon the date of postmark of the mailing.

(f) Health Care Providers shall be responsible for obtaining proof in writing that a specific claim was delivered to a Health Plan Administrator on a specific date for determining the time periods for the purposes of prompt payment.

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(g) Notwithstanding any provisions to the contrary, interest shall be allowed to accrue at a rate of 12% per annum as damages for money owed by a Health Plan Administrator for payment of a Clean Claim, or portion thereof, that exceeds the applicable reimbursement time limitations under this Section, including applicable costs for collecting past due payments as provided in § 9905 of this Article, as follows:

(1) for an uncontested Clean Claim:

(i) filed in writing, interest from the first calendar day after the 45-day period in § 9902(b); or

(2) for a contested claim, or portion thereof, filed in writing:

(i) for which notice was provided under § 9902(c), interest from the first calendar day forty-five (45) days after the date the additional information is received; or

(ii) for which notice was not provided, but not within the time specified under § 9902(c), interest from the first calendar day after the claim is received.

(h) Each Health Care Provider shall notify the Health Plan Administrator and patient in writing of all claims for which they intend to charge interest. Any interest that accrues as a result of the delayed payment of a Clean Claim, or any portion thereof, in accordance with the provisions of this Act shall be automatically added by the Health Plan Administrator to the amount of the unpaid Clean Claims due the Health Care Provider.

(i) Interest shall only apply to the principal portion of the claim.

(j) The provisions of this Section shall not apply to the payment or reimbursement of any claim, or portion thereof, involving a Coordination of Benefits between multiple payers of a claim.