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Nutmeg State: Minimize Health Claim Disputes

By Staff Writer

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The Connecticut Insurance Department says health insurers in the state should make sure they have legitimate reasons when using “disputes” to justify failures to meet prompt-payment deadlines.

Connecticut normally requires health insurers and other providers to pay claims within 45 days.

“Acceptable legitimate disputes” warranting investigations and delays include efforts to get the information necessary to determine whether a claim is medically necessary, efforts to determine whether the services on a claim are “consistent with emergency treatment,” and efforts to investigate accident or cases of suspected fraud, officials write in Connecticut Bulletin HC-69.

When, for example, an insurer is seeking medical information, the “investigations should be limited to issues having a direct relationship to the alleged pre-existing claim or condition which is the subject of the claim,” officials write in the bulletin. “Any investigation done that is not consistent with the terms of HC-66 may be considered to be post claim underwriting.”