An insurer shall either pay or deny a clean claim within 40 days of receipt of the claim if submitted manually and within 30 days of receipt of the claim if submitted electronically. An insurer shall, within 30 days after receipt of a claim, request electronically or in writing from the person submitting the claim any information or documentation that the insurer reasonably believes will be required to process and pay the claim or to determine if the claim is a clean claim, and may make on follow up request within 15 days of having received such information. Unpaid claims accrue interest at a rate of ten percent per annum for each day they remain overdue. In the event of a request for overpayment submitted by a health plan, provider may within 40 days demand written explanation of the reasons for denial, and may provide a written notice of dispute within 30 days of having received the explanation. Any provider who suffers loss as the result of an insurer’s violation of any provision of the prompt pay law or an insurer’s breach of any provider contract provision may initiate an action to recover actual damages, including attorneys’ fees and costs. In addition, providers invoking rights protected from retribution by health plans.

Link to Existing Law: WV Code Ch 33 Article 45 Section 33-45-2

Health plan includes any individual or group health care plan, health services plan, insurance policy, managed care health insurance plan, health maintenance organization, or a third-party administrator or an intermediary thereof, thus the law would likely apply to PBMs. In addition, this law is benefitted by the existence of an express private right of action, allowing for recovery of attorneys’ fees.