Licensed insurers and managed care plans shall pay clean claims and the uncontested portions of a contested claim submitted by a health care provider within 45 days of the licensed insurer’s or managed care plan’s receipt of the claim from the health care provider (30 days for health care providers having entered into a participation agreement). Interest due to a health care provider on a clean claim shall be calculated and paid by the licensed insurer or managed care plan to the health care provider and shall be added to the amount owed on the clean claim. The interest shall be paid within 30 days of the payment of the claim. In the event of a dispute, Health care providers may file a complaint, either individually or in batches, with the Department of Insurance prior to receipt of a determination from a licensed insurer or managed care plan as to whether a claim is considered a clean claim.

Link to Existing Law: 031 Pa. Code Section 154.18

This law would benefit from language specifically extending the application to PBMs, explicitly. In addition, the law would benefit from clarification as to statutory interest calculation, and stronger enforcement tools, including a private right of action.