When can I file a complaint against a health plan for not paying the claim?

Complaints can only be filed on the appropriate Clean Claim Report form (FIS- 0284) for services that were performed on or after October 1, 2002. As a provider, you must allow the health plan 45 days within which to pay the claim before you can file a complaint with the Commissioner, so the earliest date you could file a claim would be November 15, 2002. Please note you must fill out a separate form FIS-0284 for each claim.

Who can file a prompt payment grievance?

Any medical provider, whether a health professional or health facility may file a complaint for late payment of a claim.

What health plans are subject to the prompt payment procedures?

Health insurance companies, medicare supplement insurers, long-term care insurance companies, multiple employer welfare arrangements (MEWAs), health maintenance organizations (HMOs), and non-profit health care corporations (Blue Cross/Blue Shield of Michigan).

If I have performed a service for a Medicaid patient, can I use this grievance process to get that claim paid?

No, Medicaid clean claim payment grievances must be filed on form FIS-0278. These complaints are subject to the Medicaid Clean Claim Payment provisions found in the Social Welfare Act. Different procedures are used to review and resolve these complaints. Please see Bulletin No. 00-09 for more information about Medicaid grievances.

What is a "clean claim?"

A clean claim must contain all of the following information:

1. It must identify the health professional or health facility that provided the service to verify, if necessary, affiliation status and includes any identifying numbers.
2. It must sufficiently identify the patient and health plan subscriber.
3. It must list the dates and places of service.
4. It must be a claim for a covered service for an eligible individual.
5. If necessary, it must substantiate the medical necessity and appropriateness of the service provided.
6. If prior authorization is required for certain patient services, it must contain information sufficient to establish that prior authorization was obtained.
7. It must identify the service rendered using a generally accepted system of procedure o service coding.
8. It must include additional documentation based on services rendered as reasonably required by the health plan.

Once I file a grievance for late payment of a clean claim, will the claim then be paid?

The Commissioner will investigate allegations of late payments using the information on the FIS-0284. If the Commissioner finds that the plan has a pattern of non-compliance, he will seek appropriate penalties, including the payment of the late claims with interest.

What happens if a health plan or a provider violates the timely payments process procedures contained in the Act?

Under the provisions of the Act, the Commissioner will be able to assess and collect a civil fine from the health plan or the provider for violation of the clean claim payment procedures.

Who can I call if I have a question about the prompt payment claim procedures?

You may call the Office of Financial and Insurance Regulation toll free at 877-999-6442.