Prompt Payment of Health Benefits Claims Act of 2004
A bill to provide for prompt payment and interest on late payments of health care claims.
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Read twice and referred to the Committee on Health, Education, Labor, and Pensions. (text of measure as introduced: CR S4046-4048)
April 8, 2004
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Introduced in Senate
April 8, 2004
Sponsor introductory remarks on measure. (CR S4046)
April 8, 2004
Read twice and referred to the Committee on Health, Education, Labor, and Pensions. (text of measure as introduced: CR S4046-4048)
April 8, 2004
Floor Debate
13 membersWhat members said about S. 2308 on the floor




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Floor Debate
13 membersWhat members said about S. 2308 on the floor
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Bill Text
Latest available legislative text
[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[S. 2308 Introduced in Senate (IS)]
2d Session
S. 2308
To provide for prompt payment and interest on late payments of health
care claims.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
April 8, 2004
Mr. Corzine (for himself, Mr. Reed, Mr. Bingaman, Mr. Lautenberg, and
Ms. Cantwell) introduced the following bill; which was read twice and
referred to the Committee on Health, Education, Labor, and Pensions
_______________________________________________________________________
A BILL
To provide for prompt payment and interest on late payments of health
care claims.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Prompt Payment of Health Benefits
Claims Act of 2004''.
SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974.
(a) In General.--Subpart B of part 7 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et
seq.) is amended by adding at the end the following:
``SEC. 714. PROMPT PAYMENT OF HEALTH BENEFITS CLAIMS.
``(a) Timeframe for Payment of Complete Claim.--A group health
plan, and a health insurance issuer offering group health insurance
coverage in connection with a group health plan, shall pay all complete
claims and uncontested claims--
``(1) in the case of a claim that is submitted
electronically, within 14 days of the date on which the claim
is submitted; or
``(2) in the case of a claim that is not submitted
electronically, within 30 days of the date on which the claim
is submitted.
``(b) Procedures Involving Submitted Claims.--
``(1) In general.--Not later than 10 days after the date on
which a complete claim is submitted, a group health plan, and a
health insurance issuer offering group health insurance
coverage in connection with a group health plan, shall provide
the claimant with a notice that acknowledges receipt of the
claim by the plan or issuer. Such notice shall be considered to
have been provided on the date on which the notice is mailed or
electronically transferred.
``(2) Claim deemed to be complete.--A claim is deemed to be
a complete claim under this section if the group health plan or
health insurance issuer involved does not provide notice to the
claimant of any deficiency in the claim within 10 days of the
date on which the claim is submitted.
``(3) Incomplete claims.--
``(A) In general.--If a group health plan or health
insurance issuer determines that a claim for health
care expenses is incomplete, the plan or issuer shall,
not later than the end of the period described in
paragraph (2), notify the claimant of such
determination. Such notification shall specify all
deficiencies in the claim and shall list all additional
information or documents necessary for the proper
processing and payment of the claim.
``(B) Determination after submission of additional
information.--A claim is deemed to be a complete claim
under this paragraph if the group health plan or health
insurance issuer involved does not provide notice to
the claimant of any deficiency in the claim within 10
days of the date on which additional information is
received pursuant to subparagraph (A).
``(C) Payment of uncontested portion of a claim.--A
group health plan or health insurance issuer shall pay
any uncontested portion of a claim in accordance with
subsection (a).
``(4) Obligation to pay.--A claim for health care expenses
that is not paid or contested by a group health plan or health
insurance issuer within the timeframes set forth in this
subsection shall be deemed to be a complete claim and paid by
the plan or issuer in accordance with subsection (a).
``(c) Date of Payment of Claim.--Payment of a complete claim under
this section is considered to have been made on the date on which full
payment is received by the health care provider.
``(d) Interest Schedule.--
``(1) In general.--With respect to a complete claim, a
group health plan or health insurance issuer that fails to
comply with subsection (a) shall pay the claimant interest on
the amount of such claim, from the date on which such payment
was due as provided in this section, at the following rates:
``(A) 1\1/2\ percent per month from the 1st day of
nonpayment after payment is due through the 15th day of
such nonpayment.
``(B) 2 percent per month from the 16th day of such
nonpayment through the 45th day of such nonpayment.
``(C) 2\1/2\ percent per month after the 46th day
of such nonpayment.
``(2) Contested claims.--With respect to claims for health
care expenses that are contested by the plan or issuer, once
such claim is deemed complete under subsection (b), the
interest rate applicable for noncompliance under this
subsection shall apply consistent with paragraphs (1) and (2).
``(e) Private Right of Action.--Nothing in this section shall be
construed to prohibit or limit a claim or action not covered by the
subject matter of this section that any claimant has against a group
health plan, or a health insurance issuer.
``(f) Anti-Retaliation.--Consistent with applicable Federal or
State law, a group health plan or health insurance issuer shall not
retaliate against a claimant for exercising a right of action under
this section.
``(g) Fines and Penalties.--
``(1) Fines.--
``(A) In general.--If a group health plan or health
insurance issuer offering group health insurance
coverage, willfully and knowingly violates this section
or has a pattern of repeated violations of this
section, the Secretary shall impose a fine not to
exceed $1,000 per claim for each day a response is
delinquent beyond the date on which such response is
required under this section.
``(B) Repeated violations.--If 3 separate fines
under subparagraph (A) are levied within a 5-year
period, the Secretary is authorized to impose a penalty
in an amount not to exceed $10,000 per claim.
``(2) Remedial action plan.--Where it is established that
the group health plan or health insurance issuer willfully and
knowingly violated this section or has a pattern of repeated
violations, the Secretary shall require the group health plan
or health insurance issuer to--
``(A) submit a remedial action plan to the
Secretary; and
``(B) contact claimants regarding the delays in the
processing of claims and inform claimants of steps
being taken to improve such delays.
``(h) Definitions.--In this section:
``(1) Claimant.--The term `claimant' means a participant,
beneficiary or health care provider submitting a claim for
payment of health care expenses.
``(2) Complete claim.--The term `complete claim' is a claim
for payment of covered health care expenses that--
``(A) in the case of a claim involving a health
care provider that is an institution or other facility
or agency that provides health care services, is a
properly completed billing instrument that consists
of--
``(i) the Health Care Financing
Administration 1450 (UB-92) paper form, or its
successor, as adopted by the NUBC, with data
element usage consistent with the usage
prescribed in the UB-92 National Uniform
Billing Data Elements Specification Manual,
and, for claims submitted before October 1,
2002, any State-designated data requirements
that are determined and approved by the State
uniform billing committee of the State in which
the health care service or supply is furnished;
or
``(ii) the electronic format for
institutional claims (and accompanying
implementation guide) adopted as a standard by
the Secretary of Health and Human Services
pursuant to section 1173 of the Social Security
Act (42 U.S.C. 1320d-2); and
``(B) in the case of claim involving a health care
provider that is a physician or other individual who is
licensed, accredited, or certified under State law to
provide specified health care services, is a properly
completed billing instrument that--
``(i) the Health Care Financing
Administration 1500 paper form, or its
successor, as adopted by the NUCC and further
defined by data element specifications
contained in the NUCC implementation guide or,
if such specifications are not issued by the
NUCC, the data element specifications contained
in the Medicare Carriers Manual Part 4 (HCFA-
Pub 14-4) sections 2010.1 through 2010.4; or
(ii) the electronic format for professional
claims (and accompanying implementation guide)
adopted as a standard by the Secretary of
Health and Human Services pursuant to section
1173 of the Social Security Act (42 U.S.C.
1320d-2).
``(3) Contested claim.--The term `contested claim' means a
claim for health care expenses that is denied by a group health
plan or health insurance issuer during or after the benefit
determination process.
``(4) Health care provider.--The term `health care
provider' includes a physician or other individual who is
licensed, accredited, or certified under State law to provide
specified health care services and who is operating with the
scope of such licensure, accreditation, or certification, as
well as an institution or other facility or agency that
provides health care services and is licensed, accredited, or
certified to provide health care items and services under
applicable State law.
``(5) Incomplete claim.--The term `incomplete claim' means
a claim for health care expenses that cannot be adjudicated
because it fails to include all of the required data elements
necessary for adjudication.
``(6) NUBC.--The term `NUBC' means the National Uniform
Billing Committee.
``(7) NUCC.--The term `NUCC' means the National Uniform
Claim Committee.''.
SEC. 3. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
(a) Group Market.--Subpart 2 of part A of title XXVII of the Public
Health Service Act (42 U.S.C. 300gg-4 et seq.) is amended by adding at
the end the following:
``SEC. 2707. PROMPT PAYMENT OF HEALTH BENEFITS CLAIMS.
``(a) Timeframe for Payment of Complete Claim.--A group health
plan, and a health insurance issuer offering group health insurance
coverage in connection with a group health plan, shall pay all complete
claims and uncontested claims--
``(1) in the case of a claim that is submitted
electronically, within 14 days of the date on which the claim
is submitted; or
``(2) in the case of a claim that is not submitted
electronically, within 30 days of the date on which the claim
is submitted.
``(b) Procedures Involving Submitted Claims.--
``(1) In general.--Not later than 10 days after the date on
which a complete claim is submitted, a group health plan, and a
health insurance issuer offering group health insurance
coverage in connection with a group health plan, shall provide
the claimant with a notice that acknowledges receipt of the
claim by the plan or issuer. Such notice shall be considered to
have been provided on the date on which the notice is mailed or
electronically transferred.
``(2) Claim deemed to be complete.--A claim is deemed to be
a complete claim under this section if the group health plan or
health insurance issuer involved does not provide notice to the
claimant of any deficiency in the claim within 10 days of the
date on which the claim is submitted.
``(3) Incomplete claims.--
``(A) In general.--If a group health plan or health
insurance issuer determines that a claim for health
care expenses is incomplete, the plan or issuer shall,
not later than the end of the period described in
paragraph (2), notify the claimant of such
determination. Such notification shall specify all
deficiencies in the claim and shall list all additional
information or documents necessary for the proper
processing and payment of the claim.
``(B) Determination after submission of additional
information.--A claim is deemed to be a complete claim
under this paragraph if the group health plan or health
insurance issuer involved does not provide notice to
the claimant of any deficiency in the claim within 10
days of the date on which the additional information is
received pursuant to subparagraph (A).
``(C) Payment of uncontested portion of a claim.--A
group health plan or health insurance issuer shall pay
any uncontested portion of a claim in accordance with
subsection (a).
``(4) Obligation to pay.--A claim for health care expenses
that is not paid or contested by a group health plan or health
insurance issuer within the timeframes set forth in this
subsection shall be deemed to be a complete claim and paid by
the plan or issuer in accordance with subsection (a).
``(c) Date of Payment of Claim.--Payment of a complete claim under
this section is considered to have been made on the date on which full
payment is received by the health care provider.
``(d) Interest Schedule.--
``(1) In general.--With respect to a complete claim, a
group health plan or health insurance issuer that fails to
comply with subsection (a) shall pay the claimant interest on
the amount of such claim, from the date on which such payment
was due as provided in this section, at the following rates:
``(A) 1\1/2\ percent per month from the 1st day of
nonpayment after payment is due through the 15th day of
such nonpayment.
``(B) 2 percent per month from the 16th day of such
nonpayment through the 45th day of such nonpayment.
``(C) 2\1/2\ percent per month after the 46th day
of such nonpayment.
``(2) Contested claims.--With respect to claims for health
care expenses that are contested by the plan or issuer, once
such claim is deemed complete under subsection (b), the
interest rate applicable for noncompliance under this
subsection shall apply consistent with paragraphs (1) and (2).
``(e) Private Right of Action.--Nothing in this section shall be
construed to prohibit or limit a claim or action not covered by the
subject matter of this section that any claimant has against a group
health plan, or a health insurance issuer.
``(f) Anti-Retaliation.--Consistent with applicable Federal or
State law, a group health plan or health insurance issuer shall not
retaliate against a claimant for exercising a right of action under
this section.
``(g) Fines and Penalties.--
``(1) Fines.--
``(A) In general.--If a group health plan or health
insurance issuer offering group health insurance
coverage willfully and knowingly violates this section
or has a pattern of repeated violations of this
section, the Secretary shall impose a fine not to
exceed $1,000 per claim for each day a response is
delinquent beyond the date on which such response is
required under this section.
``(B) Repeated violations.--If 3 separate fines
under subparagraph (A) are levied within a 5-year
period, the Secretary is authorized to impose a penalty
in an amount not to exceed $10,000 per claim.
``(2) Remedial action plan.--Where it is established that
the group health plan or health insurance issuer willfully and
knowingly violated this section or has a pattern of repeated
violations, the Secretary shall require the health plan or
health insurance issuer to--
``(A) submit a remedial action plan to the
Secretary; and
``(B) contact claimants regarding the delays in the
processing of claims and inform claimants of steps
being taken to improve such delays.
``(h) Definitions.--In this section:
``(1) Claimant.--The term `claimant' means an enrollee or
health care provider submitting a claim for payment of health
care expenses.
``(2) Complete claim.--The term `complete claim' is a claim
for payment of covered health care expenses that--
``(A) in the case of a claim involving a health
care provider that is an institution or other facility
or agency that provides health care services, is a
properly completed billing instrument that consists
of--
``(i) the Health Care Financing
Administration 1450 (UB-92) paper form, or its
successor, as adopted by the NUBC, with data
element usage consistent with the usage
prescribed in the UB-92 National Uniform
Billing Data Elements Specification Manual,
and, for claims submitted before October 1,
2002, any State-designated data requirements
that are determined and approved by the State
uniform billing committee of the State in which
the health care service or supply is furnished;
or
``(ii) the electronic format for
institutional claims (and accompanying
implementation guide) adopted as a standard by
the Secretary of Health and Human Services
pursuant to section 1173 of the Social Security
Act (42 U.S.C. 1320d-2); and
``(B) in the case of claim involving a health care
provider that is a physician or other individual who is
licensed, accredited, or certified under State law to
provide specified health care services, is a properly
completed billing instrument that--
``(i) the Health Care Financing
Administration 1500 paper form, or its
successor, as adopted by the NUCC and further
defined by data element specifications
contained in the NUCC implementation guide or,
if such specifications are not issued by the
NUCC, the data element specifications contained
in the Medicare Carriers Manual Part 4 (HCFA-
Pub 14-4) sections 2010.1 through 2010.4; or
``(ii) the electronic format for
professional claims (and accompanying
implementation guide) adopted as a standard by
the Secretary of Health and Human Services
pursuant to section 1173 of the Social Security
Act (42 U.S.C. 1320d-2).
``(3) Contested claim.--The term `contested claim' means a
claim for health care expenses that is denied by a group health
plan or health insurance issuer during or after the benefit
determination process.
``(4) Health care provider.--The term `health care
provider' includes a physician or other individual who is
licensed, accredited, or certified under State law to provide
specified health care services and who is operating with the
scope of such licensure, accreditation, or certification, as
well as an institution or other facility or agency that
provides health care services and is licensed, accredited, or
certified to provide health care items and services under
applicable State law.
``(5) Incomplete claim.--The term `incomplete claim' means
a claim for health care expenses that cannot be adjudicated
because it fails to include all of the required data elements
necessary for adjudication.
``(6) NUBC.--The term `NUBC' means the National Uniform
Billing Committee.
``(7) NUCC.--The term `NUCC' means the National Uniform
Claim Committee.''.
(b) Individual Market.--Part B of title XXVII of the Public Health
Service Act (42 U.S.C. 300gg-41 et seq.) is amended--
(1) by redesignating the first subpart 3 (relating to other
requirements) as subpart 2; and
(2) by adding at the end of subpart 2 the following:
``SEC. 2753. STANDARDS RELATING TO PROMPT PAYMENT OF HEALTH BENEFITS
CLAIMS.
``The provisions of section 2707 shall apply to health insurance
coverage offered by a health insurance issuer in the individual market
in the same manner as they apply to health insurance coverage offered
by a health insurance issuer in connection with a group health plan in
the small or large group market.''.
SEC. 4. AMENDMENTS TO THE SOCIAL SECURITY ACT.
(a) Medicare.--
(1) Medicare advantage plans.--Section 1857(f) of the
Social Security Act (42 U.S.C. 1395w-27(f)) is amended--
(A) in paragraph (1), by striking ``consistent with
the provisions of sections 1816(c)(2) and 1842(c)(2)''
and inserting ``consistent with the provisions of
section 2707 of the Public Health Service Act''; and
(B) in paragraph (2)--
(i) in the second sentence, by inserting
``and to reflect the amount of any fines or
penalties imposed pursuant to the provisions of
section 2707(g) of the Public Health Service
Act'' before the period at the end; and
(ii) by inserting before the second
sentence the following new sentence: ``Payment
of such amounts shall include any interest due
pursuant to the provisions of section 2707(d)
of the Public Health Service Act.''.
(2) Prescription drug plans.--Section 1860D-12(b)(3) of the
Social Security Act (42 U.S.C.1395w-112(b)(3)) is amended--
(A) by redesignating subparagraphs (E) and (F) as
subparagraphs (F) and (G), respectively; and
(B) by inserting after subparagraph (D) the
following new subparagraph:
``(E) Prompt payment by medicare advantage
organization.--Section 1857(f).''.
(b) Medicaid.--Section 1932(f) of the Social Security Act (42
U.S.C. 1396u-2(f)) is amended by striking ``the claims payment
procedures described in section 1902(a)(37)(A), unless the health care
provider and the organization agree to an alternate payment schedule''
and inserting ``section 2707 of the Public Health Service Act''.
(c) Effective Date.--The amendments made by this section shall
apply to plan years beginning after December 31, 2004.
SEC. 5. PREEMPTION.
The provisions of this Act shall not supersede any contrary
provision of State law if the provision of State law imposes
requirements, standards, or implementation specifications that are
equal to or more stringent than the requirements, standards, or
implementation specifications imposed under this Act, and any such
requirements, standards, or implementation specifications under State
law that are equal to or more stringent than the requirements,
standards, or implementation specifications under this Act shall apply
to group health plans and health insurance issuers as provided for
under State law.
SEC. 6. EFFECTIVE DATE.
(a) In General.--Except as provided in this section, the amendments
made by this Act shall apply with respect to group health plans and
health insurance issuers for plan years beginning after December 31,
2004.
(b) Special Rule for Collective Bargaining Agreements.--In the case
of a group health plan maintained pursuant to one or more collective
bargaining agreements between employee representatives and one or more
employers ratified before the date of the enactment of this Act, the
amendments made by this Act shall not apply to plan years beginning
before the later of--
(1) the date on which the last of the collective bargaining
agreements relating to the plan terminates (determined without
regard to any extension thereof agreed to after the date of the
enactment of this Act), or
(2) January 1, 2005.
For purposes of paragraph (1), any plan amendment made pursuant to a
collective bargaining agreement relating to the plan which amends the
plan solely to conform to any requirement of the amendments made by
this section shall not be treated as a termination of such collective
bargaining agreement.
SEC. 7. SEVERABILITY.
If any provision of this Act, or an amendment made by this Act, is
held by a court to be invalid, such invalidity shall not affect the
remaining provisions of this Act, or amendments made by this Act.
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