Iowa Admin. Code r. 441-73.23

Current through Regsiter Vol. 46, No. 26, June 12, 2024

Rule 441-73.23 - Claims payment by the MCP

(1) The managed care organizations shall pay or deny:

a. Ninety percent of all clean claims within 30 calendar days of receipt,

b. Ninety-nine point five percent of all clean claims within 90 calendar days of receipt, and

c. Ninety-five percent of all claims within 45 calendar days of receipt.

(2) The PAHP shall pay or deny:

a. Ninety percent of all clean claims within 14 calendar days of receipt,

b. Ninety-nine percent of all clean claims within 90 calendar days of receipt, and

c. Ninety-five percent of all claims within 21 calendar days of receipt.

(3) Managed care limits on payment responsibility for services.

a. The MCP is not required to reimburse providers for the provision of services that do not meet the criteria of medical necessity.

b. The MCP has the right to require prior authorization of covered services and to deny reimbursement to providers that do not comply with such requirements.

c. Payment responsibilities for emergency room services are as provided in rule 441-73.7 (249A).

(4) Payment to nonparticipating providers. In reimbursing nonparticipating providers, the managed care organization is obligated to pay 80 percent of the payment to participating providers.

Iowa Admin. Code r. 441-73.23

Adopted by IAB January 6, 2016/Volume XXXVIII, Number 14, effective 1/1/2016

Amended by IAB April 5, 2023/Volume XLV, Number 20, effective 6/1/2023