P.R. Laws tit. 26, § 3004
The insurer or health services organization shall notify the participating providers, in writing or electronically, of those claims that are not actionable for payment within a term of thirty (30) calendar days after receiving the claim. The notice shall clearly indicate the reasons for which the insurer or health services organization deems that the claim is not actionable for payment, indicating the documents or additional information that must be submitted so that it may be processed.
Within the following twenty (20) days of having received the notice of the insurer or health services organization, the participating provider must answer the same. The failure to do so shall be deemed to be an admission of the deficiencies notified. Once the participating provider submits the required information or documents, the insurer or health services organization shall proceed to pay the claim within the thirty (30) days following the receipt of the information or documents.
From the date that the insurer or health services organization receives a claim submitted by the participating provider, two (2) terms elapse concurrently, one thirty (30)-day term for the payment of clean claims as established in § 3002 of this title, and one thirty (30)-day term for the insurer or health services organization to remit the notice of claim payment denial to the participating provider. Any claim or part of the claim undisputed by the insurer or health services organization within the aforementioned thirty (30)-day term shall be deemed to be a clean claim. Said action entails the no interruption of the preceding thirty (30)-day term for the payment of claims. The erroneous notification of a non-actionable claim shall not interrupt the thirty (30)-day term for payment, thus, the insurer or health services organization shall proceed to pay the amount claimed, plus interest, as provided in §§ 3005 and 3006 of this title.
No insurer or health services organization shall refuse to pay a claim for services rendered because of unilateral alterations or amendments to the terms of the contract between the insurer or health services organization and the subscriber or between the insurer or health services organization and the provider, including amendments to the rates.
History —Ins. Code, added as § 30.050 on July 7, 2002, No. 104, § 1; July 27, 2011, No. 150, § 3; Sept. 25, 2012, No. 265, § 1.