Ala. Admin. Code r. 482-1-079-.18
All licensed HMO's shall consider claims made under their health care contracts and, if found to be valid and proper, shall pay such claims within forty-five (45) days after the receipt of proof of the fact and amount of loss sustained under such contracts. If reasonable proof is not supplied as to the entire claim, the amount supported by reasonable proof shall be considered overdue if not paid within forty-five (45) days after such proof is received by the HMO. Any part or all of the remainder of the claim that is later supported by reasonable proof shall be considered overdue if not paid within forty-five (45) days after such proof is received by the HMO. For the purposes of calculating the extent to which any benefits are overdue, payment shall be treated as made on the date a draft or other valid instrument was placed in the United States mail to the last known address of the claimant or provider in a properly addressed, postpaid envelope, or, if not so posted, on the date of delivery. When the claim is overdue or denied, the HMO must provide written justification within five days of the overdue or denial date to any providers involved and to the enrollee if the enrollee is financially liable for the denied claim.
The above required payment time period of forty-five (45) days is not applicable if the HMO has approved executed provider contracts in which the HMO and the provider have agreed to a different schedule of payment, in which case, all other provisions set out above will be applicable with the exception that the time payment will be in accordance with the approved contract between the HMO and the provider.
Author: Commissioner of Insurance
Ala. Admin. Code r. 482-1-079-.18
Statutory Authority:Code of Ala. 1975, §§ 27-2-17, 27-21A-19.