Okla. Admin. Code § 365:40-5-127

Current through Vol. 42, No. 8, January 2, 2025

Section 365:40-5-127 - Disclosure of processing procedures

(a) In contracts with providers, or in the provider manual or other document that sets forth the procedure for filing claims as required by O.A.C. 365:40-5-122, or by any other method mutually agreed upon by the contracting parties, an HMO shall disclose to its providers:

(1) The mailing address, including a physical address, where claims are to be sent for processing whether it be the address of the HMO, a delegated claims processor, or any other entity, including a clearing house or a repricing company designated by the HMO to receive claims;

(2) The telephone number to which providers' questions and concerns regarding claims may be directed; and

(3) The mailing address, including physical address, of any separate claims processing centers for specific types of services, if applicable.

(b) An HMO shall provide no less than sixty (60) calendar days prior written notice of any changes of address for submission of claims, and of any changes of delegation of claims payment functions, to all affected providers with whom the HMO has contracts. Except an HMO may provide less than sixty (60) days notice in situations beyond the control of the HMO.

(c) After a change of claims payment address or a change in delegation of claims payment functions, an HMO shall not premise the denial of a clean claim upon a provider's failure to file a clean claim within any contracted time period for claim filing, unless timely written notice has been given to the provider.

(d) If an HMO has delegated its claims processing functions to a third party, the delegation agreement must provide that the claims processing entity shall comply with the requirements of this Part and applicable law. Any delegation agreement or provision may not be construed to limit the HMO's authority or responsibility to comply with all applicable statutory and regulatory requirements.

Okla. Admin. Code § 365:40-5-127

Added at 21 Ok Reg 77, eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff 7-14-04