OAR 836-052-0770: Prompt Payment of Clean Claims

(1) For purposes of this rule: (a) “Claim” means a request for payment of benefits under an in-force policy, regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met. (b) “Clean claim” means a claim that has no defect or impropriety, including any lack of required substantiating documentation, such as satisfactory evidence of expenses incurred, or particular circumstance requiring special treatment that prevents timely payment from being made on the claim. (2) Within 30 business days after receipt of a claim for benefits under a long term care insurance policy or certificate, an insurer shall pay the claim if it is a clean claim, or send a written notice acknowledging the date of receipt of the claim and one of the following: (a) The insurer is declining to pay all or part of the claim and the specific reason for denial; or (b) That additional information is necessary to determine if all or any part of the claim is payable and the specific additional information that is necessary. (3) Within 30 business days after receipt of all the requested additional information, an insurer shall pay a claim for benefits under a long term care insurance policy or certificate if it is a clean claim, or send a written notice that the insurer is declining to pay all or part of the claim, and the specific reason for denial. (4) If an insurer fails to comply with section (2) or (3) of this rule, such insurer shall pay interest at the rate of 1% per month on the amount of the claim that should have been paid but that remains unpaid 45 business days after the receipt of the claim with respect to section (2) of this rule or all requested additional information with respect to section (3) of this rule. The interest payable under this section shall be included in any late reimbursement without requiring the person who filed the original claim to make any additional claim for the interest. (5) The provisions of this rule shall not apply where the insurer has a reasonable basis supported by specific information that a claim was fraudulently submitted. (6) Any violation of this rule by an insurer if committed flagrantly and in conscious disregard of the provisions of this rule or with such frequency as to constitute a general business practice shall be considered a violation of the ORS 746.230. (7) The requirements of this rule apply to a long term care insurance policy issued or renewed after July 1, 2012. (8) The provisions of this rule supersede any other claim payment requirement found in ORS 746.230.