Clean Claim Act- Michigan

Michigan Law Requires Insurers to Pay Interest on Clean Claims Not Timely Paid
​
Clean Claims Act 
A clean claim must be paid within 45 days after it is received by the "health plan." The 45-day time period is tolled from the date the health plan notifies a health care provider that the claim contains defects. A health plan must notify the health care provider within 30 days after receipt of the claim by the health plan of all known reasons that prevent the claim from being a clean claim. If a health plan determines that 1 or more services listed on a claim are payable, the health plan shall pay for those services and shall not deny the entire claim because 1 or more other services listed on the claim are defective. A health care provider has 45 days, and any additional time the health plan permits, after receipt of a notice to correct all known defects. If a health care provider's response makes the claim a clean claim, the health plan shall pay the health care provider within the 45-day time period, excluding any time period tolled. If a health care provider's response does not make the claim a clean claim, the health plan shall notify the health care provider of an adverse claim determination and of the reasons for the adverse claim determination within the 45-day time period. A health care provider shall not resubmit the same claim to the health plan unless the 45-day time frame has passed.

Definition of a Clean Claim
​A "clean claim" means a claim that does all of the following:

1. Identifies the health professional, health facility, home health care provider, or durable medical equipment provider that provided service sufficiently to verify, if necessary, affiliation status and includes any identifying numbers.
2. Sufficiently identifies the patient and health plan subscriber.
3. Lists the date and place of service.
4. Is a claim for covered services for an eligible individual.
5. If necessary, substantiates the medical necessity and appropriateness of the service provided.
6. If prior authorization is required for certain patient services, contains information sufficient to establish that prior authorization was obtained.
7. Identifies the service rendered using a generally accepted system of procedure or service coding.
8. Includes additional documentation based upon services rendered as reasonably required by the health plan.

Penalties for Late Payment of a Clean Claim
A clean claim that is not paid within 45 days shall bear simple interest at a rate of 12% per annum. The Director of DIFS may also impose a civil fine of not more than $1,000.00 for each violation not to exceed $10,000.00 in the aggregate for multiple violations.

Filing a Clean Claim Complaint with the Department of Insurance and Financial Services
A health care provider alleging that a clean claim has not been timely processed or paid may file a complaint with DIFS on form FIS 0284 and has a right to a determination of the matter by the Director or his or her designee. A health care provider or health plan may also seek court action. A health care provider can file a clean claim complaint. Individuals or policyholders cannot file a clean claim complaint. A health plan shall not terminate the affiliation status or the participation of a health care provider with a health maintenance organization provider panel or otherwise discriminate against a health care provider because the provider alleges that a health plan has violated Section 2006(7) to (14) of the Insurance Code.