(A) For each clean claim with respect to which an insurer has directed the issuance of a check or the electronic funds transfer later than the applicable period specified in § 38-59-230, the insurer shall pay interest in the same manner and at the same rate set forth in § 34-31-20(A) on the balance due on each claim computed from the twenty-first or the forty-first business day, as appropriate, based on the circumstances described in § 38-59-230, up to the date on which the insurer directs the issuance of the check or the electronic funds transfer for payment of the clean claim. At the insurer’s election, interest paid pursuant to this section must be included in the claim payment check or wire transfer or must be remitted periodically, but at least quarterly, in a separate check or wire transfer along with a report detailing the claims for which interest is being paid.

(B) No insurer has an obligation to make any interest payment pursuant to subsection (A):

Terms Used In South Carolina Code 38-59-240

  • Clean claim: means an eligible electronic or paper claim for reimbursement that:

    (a) is received by the insurer within one hundred twenty business days of the date the health care services at issue were performed;

    (b)(i) when submitted via paper has all the elements of the standardized CMS 1500 or UB 04 claim form, or the successor of each as either may be amended from time to time; or

    (ii) when submitted via an electronic transaction, uses only permitted standard code sets and has all the elements of the standard electronic formats as required by the Health Insurance Portability and Accountability Act of 1996 and other federal and state regulatory authority;

    (c) is for health care services covered by the health insurance plan and rendered to an insured person by a provider eligible for reimbursement under the health insurance plan;

    (d) has any corresponding referral that may be required for the applicable claim;

    (e) is a claim for which the insurer is the primary payor, or for which the insurer's responsibility as a secondary payor has been clearly established;

    (f) has no material defect, error, or impropriety that would affect the adjudication of the claim;

    (g) includes all required substantiating documentation or coding;

    (h) is not subject to any particular circumstance that the insurer reasonably believes, subject to review by the Department of Insurance, would prevent accurate or timely payment from being made on the claim under the terms of the health insurance plan, the participating provider agreement, or the insurer's published filing requirements; and

    (i) is under a health insurance plan for which the insurer has been timely paid all applicable premiums. See South Carolina Code 38-59-210
  • Electronic funds transfer: The transfer of money between accounts by consumer electronic systems-such as automated teller machines (ATMs) and electronic payment of bills-rather than by check or cash. (Wire transfers, checks, drafts, and paper instruments do not fall into this category.) Source: OCC
  • Force majeure: means any act of God, governmental act, act of terrorism, war, fire, flood, earthquake, hurricane, or other natural disaster, explosion or civil commotion. See South Carolina Code 38-59-210
  • Insurer: means an insurance company, a health maintenance organization, and any other entity providing health insurance coverage, as defined in § 38-71-670(6), which is licensed to engage in the business of insurance in this State and which is subject to state insurance regulation. See South Carolina Code 38-59-210
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • Participating provider: means a provider who provides covered health care services to an insured or a member pursuant to a contract with an insurer or health insurance plan. See South Carolina Code 38-59-210
  • Provider: means a physician, hospital, or other person properly licensed, certified, or permitted, where required, to furnish health care services. See South Carolina Code 38-59-210

(1) with respect to any clean claim if within twenty business days of the submission of an original claim submitted electronically or within forty business days of an original claim submitted via paper, a duplicate claim is submitted while the adjudication of the original claim is still in process;

(2) to any participating provider who balance bills a plan member in violation of the participating provider‘s agreement with the insurer;

(3) with respect to any time period during which a force majeure prevents the adjudication of claims; or

(4) when payment is made to a plan member.

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