South Carolina Code 38-59-230. Time frame for payment of clean claims; acknowledging receipt of claim; processing of electronic claims by billing service
(1) to determine that such claim does not contain any material defect, error, or impropriety; or
Terms Used In South Carolina Code 38-59-230
- Clean claim: means an eligible electronic or paper claim for reimbursement that:
(a) is received by the insurer within one hundred twenty business days of the date the health care services at issue were performed;
(b)(i) when submitted via paper has all the elements of the standardized CMS 1500 or UB 04 claim form, or the successor of each as either may be amended from time to time; or
(ii) when submitted via an electronic transaction, uses only permitted standard code sets and has all the elements of the standard electronic formats as required by the Health Insurance Portability and Accountability Act of 1996 and other federal and state regulatory authority;
(c) is for health care services covered by the health insurance plan and rendered to an insured person by a provider eligible for reimbursement under the health insurance plan;
(d) has any corresponding referral that may be required for the applicable claim;
(e) is a claim for which the insurer is the primary payor, or for which the insurer's responsibility as a secondary payor has been clearly established;
(f) has no material defect, error, or impropriety that would affect the adjudication of the claim;
(g) includes all required substantiating documentation or coding;
(h) is not subject to any particular circumstance that the insurer reasonably believes, subject to review by the Department of Insurance, would prevent accurate or timely payment from being made on the claim under the terms of the health insurance plan, the participating provider agreement, or the insurer's published filing requirements; and
(i) is under a health insurance plan for which the insurer has been timely paid all applicable premiums. See South Carolina Code 38-59-210 - Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
- Electronic funds transfer: The transfer of money between accounts by consumer electronic systems-such as automated teller machines (ATMs) and electronic payment of bills-rather than by check or cash. (Wire transfers, checks, drafts, and paper instruments do not fall into this category.) Source: OCC
- Insurer: means an insurance company, a health maintenance organization, and any other entity providing health insurance coverage, as defined in § 38-71-670(6), which is licensed to engage in the business of insurance in this State and which is subject to state insurance regulation. See South Carolina Code 38-59-210
- Provider: means a physician, hospital, or other person properly licensed, certified, or permitted, where required, to furnish health care services. See South Carolina Code 38-59-210
(2) to make a payment determination.
(B) An insurer shall direct the issuance of a check or an electronic funds transfer in payment for a clean claim that is submitted electronically within twenty business days following the later of the insurer’s receipt of the claim or the date on which the insurer is in receipt of all information needed and in a format required for the claim to constitute a clean claim and is in receipt of all documentation which may be requested by an insurer which is reasonably needed by the insurer:
(1) to determine that such claim does not contain any material defect, error, or impropriety; or
(2) to make a payment determination.
(C) An insurer shall affix to or on paper claims, or otherwise maintain a system for determining, the date claims are received by the insurer. An insurer shall send an electronic acknowledgement of claims submitted electronically either to the provider or the provider’s designated vendor for the exchange of electronic health care transactions. The acknowledgement must identify the date claims are received by the insurer. If an insurer determines that there is any defect, error, or impropriety in a claim that prevents the claim from entering the insurer’s adjudication system, the insurer shall provide notice of the defect or error either to the provider or the provider’s designated vendor for the exchange of electronic health care transactions within twenty business days of the submission of the claim if it was submitted electronically or within forty business days of the claim if it was submitted via paper. Nothing contained in this section is intended or may be construed to alter an insurer’s ability to request clinical information reasonably necessary for the proper adjudication of the claim or for the purpose of investigating fraudulent or abusive billing practices.
(D) A clearinghouse, billing service, or any other vendor that contracts with a provider to deliver health care claims to an insurer on the provider’s behalf is prohibited from converting electronic claims received from the provider into paper claims for submission to the insurer. A violation of this subsection constitutes an unfair trade practice under Chapter 5 of Title 39, and individual providers and insurers injured by violations of this subsection have an action for damages as set forth in § 39-5-140.