I have received a number of questions and requests in the past two months regarding difficult insurance issues encountered by OPA members. The problems involved range from delayed reimbursement to challenges with prior authorizations. Since many of these difficulties stem from a few basic core issues, I thought it might be helpful, now and in the next few weeks, to remind everyone of a few important consumer and provider protection laws which give needed support for nearly every practicing psychologist who must interact with health insurance companies.
The first of these is Ohio’s Prompt Payment Law, which establishes strict time frames for the processing and payment of claims by insurance companies. Specifically, the law states:
- A third-party payer has fifteen (15) days from receipt to notify a provider when a materially deficient claim is received. Examples of materially deficient claims include claims with an incorrect patient name or benefit contracts number, a patient that cannot be identified, a claim without as or treatment code or a claim without a provider's identifying number. The fifteen (15) day time period and the time spent correcting the deficiencies do not count toward the calculation of time in which a claim must be processed.
- A third-party payer has thirty (30) days to process a claim if no supporting documentation is needed.
- A third-party payer has forty-five (45) days to process a claim if the third-party payer requests additional supporting documentation. However, third-party payers must request supporting documentation within thirty (30) days of the initial receipt of the claim. The time period of forty-five (45) days is suspended until the third-party payer receives the last piece of information requested in the initial thirty (30) day period.
- The time period is not suspended if a third-party payer requests additional supporting documentation after receiving initially requested information.
- A request for additional supporting documentation that is made outside the thirty (30) day time period and that is based on information received in the initial request regarding a previously unknown pre-existing condition may suspend the forty-five (45) day processing time.
- A third-party payer may refuse to process a claim submitted by a provider if the provider submits the claim later than forty-five (45) days after receiving notice from a different third-party payer or a state or federal program that that payer or program is not responsible for the cost of the health care services, or if the provider does not submit the notice of denial from the different third-party payer or program with the claim.
- A third-party payer that has a timely filing requirement must process an untimely claim if all the following apply:
- The claim was initially submitted to a different third-party payer or state or federal program;
- The provider submits the claim to the second payer within forty-five (45) days of receiving notice that the first payer denied the claim; and
- The provider submits the notice of denial along with the claim
- When a claim is submitted later than one year after the last date of service for which reimbursement is sought, a third-party payer shall pay or deny the claim not later than ninety (90) days after receipt of the claim or, alternatively, pursuant to the requirements of sections 3901.381 to 3901.388 of the Revised Code.
Many reimbursement issues encountered by psychologists may be eligible for a complaint under this law. For example, an insurance company may review a claim to determine whether it was medically necessary. However, they may not withhold payment, beyond the time frames stipulated, while making this determination. The timelines above still apply.
If you need to file a Prompt Pay Law complaint or any other complaint with the Ohio Department of Insurance (ODI), the best way is to establish an ODI Provider Gateway Account. Once established, filing complaints with ODI becomes streamlined. Instructions for establishing this account with ODI may be found here:
I encourage all psychologists who interact with insurance companies to establish this account with ODI. Providers may also use a printed form:
It may be helpful to share this information with office managers. They may contact me directly for questions and support, providing they work for an OPA member. In the next few weeks, I will be providing information on more laws associated with these core issues of difficulty affecting many of us. In many cases, the solution may involve interacting with ODI, so following the above suggestion will facilitate my recommendations in the future. (Please note: ODI does not govern Medicaid or Medicare plans. Please contact me directly for help with these).
Please let me know if you have comments or questions.
Jim Broyles, PhD
OPA Director of Professional Affairs