SECOND REGULAR SESSION
HOUSE COMMITTEE SUBSTITUTE FOR
SENATE COMMITTEE SUBSTITUTE FOR
SENATE BILL NO. 762
89TH GENERAL ASSEMBLY
ANNE C. WALKER, Chief Clerk
AN ACT
To amend chapter 376, RSMo, relating to the payment of insurance claims, by adding thereto two new sections relating to the same subject.
Section A. Chapter 376, RSMo, is amended by adding thereto two new sections, to be known as sections 376.809 and 376.1225, to read as follows:
376.809. 1. To the extent consistent with the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001, et seq., this section shall apply to any health insurer as defined in section 376.806, nonprofit health service plan or health maintenance organization.
2. Within forty-five days after receipt of a claim for reimbursement from a person entitled to reimbursement, a health insurer as defined in section 376.806, nonprofit health service plan or health maintenance organization shall:
(1) Pay the claim in accordance with this section; or
(2) Send a notice of receipt and status of the claim that states:
(a) That the insurer, nonprofit health service plan, or health maintenance organization refuses to reimburse all or part of the claim and the reason for the refusal; or
(b) That additional information is necessary to determine if all or part of the claim will be reimbursed and what specific additional information is necessary.
3. If an insurer, nonprofit health service plan or health maintenance organization fails to comply with subsection 2 of this section, the insurer, nonprofit health service plan or health maintenance organization shall pay interest on the amount of the claim that remains unpaid forty-five days after the claim is filed at the monthly rate of one and one-half percent. The interest paid pursuant to this subsection shall be included in any late reimbursement without the necessity for the person that filed the original claim to make an additional claim for such interest.
4. Within ten days after the day on which all additional information is received by an insurer, nonprofit health service plan or health maintenance organization, it shall:
(1) Pay the claim in accordance with this section; or
(2) Send a written notice that:
(a) States refusal to reimburse the claim or any part of the claim; and
(b) Specifies each reason for denial.
5. An insurer, nonprofit health service plan or health maintenance organization that fails to comply with subsection 4 of this section shall pay interest on any amount of the claim that remains unpaid at the monthly rate of one and one-half percent.
376.1225. 1. Every health benefit plan as that is defined in section 376.1350 and all self-insured group health benefit plans of any type or description whether providing for coverage for specific individuals and members of their families or to groups of individuals and/or their families and all plans offered by an "insurer" as defined in section 376.821, shall provide coverage for administration of general anesthesia and hospital charges for dental care provided to the following covered persons:
(1) A child under the age of five;
(2) A person who is severely disabled; or
(3) A person who has a diagnosed medical or behavioral condition which requires hospitalization or general anesthesia when dental care is provided.
2. Each plan as described in this section must provide coverage for hospital charges and administration of general anesthesia in a participating hospital or participating surgical care center.
3. Nothing in this section shall prevent a health carrier from requiring prior authorization for hospitalization for dental care procedures in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions.
4. Nothing in this section shall apply to accident-only, dental-only specified disease, hospital indemnity, Medicare supplement, short-term major medical policies of six months or less duration or long-term care policies.