North Carolina Prompt Claim Payment Timing Law

What is the NC Law on insurance claim payment timing?


North Carolina has the General Statute 58-3-225 on prompt claim payments under health benefit plans. I assume this is the law you are referring to.

The way I understand the law is the insurer (or insurance company) has 30 days after they receive a claim to either:

  • Pay the claim.

  • Provide notice the claim was denied.

  • Provide notice that the proof of loss was inadequate or incomplete.

  • Notify the submitter that the claim was not submitted on the proper form or in the proper format - as required by the health plan or by law.

  • Notice that coordination of benefit information is needed.

  • Notice that the claim is pending because of non payment of premiums or fees.



If the claim is denied, the notice has to include all of the specific good faith reasons the claim was denied.

It looks like there are a lot more details than I've summarized above and many caveats on the law. The North Carolina Department of Insurance has published guidance on the law here. Its dated 2001 and answers a lot of questions about the specifics of the law. I couldn't find anything more current on the law to see if any changes had been made recently.

Hope this helps.

Thanks,

Gina

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