{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-1219","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-1219","heading":"Clean claims - Reimbursement - Notice of defective claims","body":"- Interest on overdue payments - Attorney's fees.\n\nA. In the administration, servicing, or processing of any\n\naccident and health insurance policy, every insurer shall reimburse\n\nall clean claims of an insured, an assignee of the insured, or a\n\nhealth care provider within forty-five (45) calendar days after\n\nreceipt of a paper claim and thirty (30) calendar days after receipt\n\nof an electronic claim by the insurer.\n\nB. As used in this section:\n\n1. \"Accident and health insurance policy\" or \"policy\" means any\n\npolicy, certificate, contract, agreement or other instrument that\n\nprovides accident and health insurance, as defined in Section 703 of\n\nthis title, to any person in this state, and any subscriber\n\ncertificate or any evidence of coverage issued by a health\n\nmaintenance organization to any person in this state;\n\n2. \"Clean claim\" means a claim that has no defect or\n\nimpropriety including a lack of any required substantiating\n\ndocumentation or particular circumstance requiring special treatment\n\nthat impedes prompt payment; and\n\n3. \"Insurer\" means any entity that provides an accident and\n\nhealth insurance policy in this state including, but not limited to,\n\na licensed insurance company, a not-for-profit hospital service and\n\nmedical indemnity corporation, a health maintenance organization, a\n\nfraternal benefit society, a multiple employer welfare arrangement,\n\nor any other entity subject to regulation by the Insurance\n\nCommissioner.\n\nC. If a claim or any portion of a claim is determined to have\n\ndefects or improprieties including a lack of any required\n\nsubstantiating documentation or particular circumstance requiring\n\nspecial treatment, the insured, enrollee or subscriber, assignee of\n\nthe insured, enrollee or subscriber, and health care provider shall\n\nbe notified in writing within thirty (30) calendar days after\n\nreceipt of the claim by the insurer. The written notice shall\n\nspecify the portion of the claim that is causing a delay in\n\nprocessing and explain any additional information or corrections\n\nneeded. Failure of an insurer to provide the insured, enrollee or\n\nsubscriber, assignee of the insured, enrollee or subscriber, and\n\nhealth care provider with the notice shall constitute prima facie\n\nevidence that the claim will be paid in accordance with the terms of\n\nthe policy. Provided, if a claim is not submitted into the system\n\ndue to a failure to meet basic Electronic Data Interchange (EDI)\n\nand/or Health Insurance Portability and Accountability Act (HIPAA)\n\nedits, electronic notification of the failure to the submitter shall\n\nbe deemed compliance with this subsection. Provided further, health\n\nmaintenance organizations shall not be required to notify the\n\ninsured, enrollee or subscriber, or assignee of the insured,\n\nenrollee or subscriber of any claim defect or impropriety.\n\nUpon receipt of the additional information or corrections which\n\nled to the claim's being delayed and a determination that the\n\ninformation is accurate, an insurer shall either pay or deny the\n\nclaim or a portion of the claim within forty-five (45) calendar days\n\nfor a paper claim and thirty (30) calendar days for an electronic\n\nclaim.\n\nD. If a clean claim or any portion of a clean claim is denied\n\nfor any reason, the insured, enrollee or subscriber, assignee of the\n\ninsured, enrollee or subscriber, and health care provider shall be\n\nnotified in writing within thirty (30) calendar days after receipt\n\nof the claim by the insurer. The written notice shall specify in\n\ndetail the reason for the denial including instructions on where a\n\nperson or entity that received notification may respond through\n\ndedicated facsimile or electronic mail message or the address or\n\nelectronic mail message address of the department of appeals of the\n\ninsurer. Upon receiving written notice of denial, a recipient may\n\nsubmit a detailed appeal in writing explaining why the claim should\ntail the reason for the denial including instructions on where a\n\nperson or entity that received notification may respond through\n\ndedicated facsimile or electronic mail message or the address or\n\nelectronic mail message address of the department of appeals of the\n\ninsurer. Upon receiving written notice of denial, a recipient may\n\nsubmit a detailed appeal in writing explaining why the claim should\n\nbe approved. If the insurer denies the appeal, the insurer shall\n\naddress in writing the specific details included in the written\n\nappeal and provide the phone number of a health plan representative\n\nat the department of appeals of the insurer.\n\nE. Payment shall be considered made on:\n\n1. The date a draft or other valid instrument which is\n\nequivalent to the amount of the payment is placed in the United\n\nStates mail in a properly addressed, postpaid envelope; or\n\n2. If not so posted, the date of delivery.\n\nF. An overdue payment shall bear simple interest at the rate of\n\nten percent (10%) per year.\n\nG. In the event litigation should ensue based upon such a\n\nclaim, the prevailing party shall be entitled to recover a\n\nreasonable attorney fee to be set by the court and taxed as costs\n\nagainst the party or parties who do not prevail.\n\nH. The Insurance Commissioner shall develop a standardized\n\nprompt pay form for use by providers in reporting violations of\n\nprompt pay requirements. The form shall include a requirement that\n\ndocumentation of the reason for the delay in payment or\n\ndocumentation of proof of payment must be provided within ten (10)\n\ndays of the filing of the form. The Commissioner shall provide the\n\nform to health maintenance organizations and providers.\n\nI. The provisions of this section shall not apply to the\n\nOklahoma Life and Health Insurance Guaranty Association or to the\n\nOklahoma Property and Casualty Insurance Guaranty Association.","path":["OK Code","Title 36"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os36.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"544e3f9486b07906fbcda47f22d3dab42ea7992e2fcbbd595f88083288a177b6","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-1217","next":"us-ok/okla.-stat.-tit.-36-36-1219.1"},"notice":"GroundRules: Original legal text. Not legal advice."}