P.R. Laws tit. 26, § 3003
The participating providers shall submit their claims on the uniform payment form provided by the insurer or health services organization, which shall indicate the information that must be enclosed, pursuant to the provisions of the Health Insurance Portability and Accountability Act of 1996, and in the regulations of the Office of the Commissioner of Insurance. The claim shall be processed if it also complies with the following requirements:
(a) It corresponds to a health service rendered by a provider to an insured person whose service is covered by a health insurance or health care plan of the insurer or health service organization, to which the claim is addressed;
(b) it includes the complete and correct information required by the Insurer or Health Service Organization provided the insurer or health service organization have notified the required information to the participating provider, and
(c) there is no controversy regarding the amount claimed.
If the insurer or health services organization does not notify any objection to a claim for payment within a term of thirty (30) days, pursuant to § 3004 of this title, it shall be understood that said claim is actionable for payment.
The insurer or health service organization may request the reimbursement of an unprocessable claim paid to the provider, within a term of six (6) years counting from the moment that the insurer or health service organization made the payment, pursuant to the procedure established by the Commissioner through regulations, and subsequently resort to the corresponding court for judicial review, if it so desires.
History —Ins. Code, added as § 30.040 on July 7, 2002, No. 104, § 1; July 27, 2011, No. 150, § 2.