Missouri Timely Filing

Overview

Revised Statutes of Missouri Section 376.383 requires all health carriers to process and pay clean claims within 45 processing days of receipt. Claims not paid within 45 days accrue interest at 1% per month plus 1% per day penalty from day 46 through day 100. Claims over $35,000 unpaid after 100 days incur 2% per month interest. The Missouri Department of Insurance, Financial Institutions and Professional Registration (DIFP) enforces this law.

Key Requirements

1. 45-Day Deadline: All health carriers must process clean claims and issue payment or denial within 45 processing days of receipt. Processing days do not include weekends and holidays.
2. Interest and Penalty Calculation: Claims unpaid from day 46 to day 100 accrue 1% per month interest plus 1% per day penalty on the claim amount. Claims exceeding $35,000 unpaid after 100 days accrue 2% per month interest in addition to interest owed through day 100.
3. Clean Claim Definition: A clean claim is a complete submission with all required information. Incomplete claims do not trigger the 45-day period; the clock restarts upon complete resubmission.
4. Fraud Suspension: If a claim is under investigation for fraud, interest and penalty accrual is suspended during the investigation period.
5. Carrier Responsibilities: Carriers must identify missing information within 10 business days and request specific deficiencies.

Penalties and Enforcement

The Missouri Department of Insurance, Financial Institutions and Professional Registration enforces timely payment and interest requirements. Health carriers failing to pay claims within 45 days and refusing to pay interest and penalties are subject to complaint investigations. Pattern violations may result in market conduct examinations, fines, and mandatory corrective action plans. Interest and penalties owed are additional to the original claim amount and are mandatory, not discretionary.

Appeals and Exceptions

Providers have the right to appeal any claim denial through the carrier's appeal process. The primary exception to the 45-day timeline is fraud investigation, during which interest and penalty accrual is suspended. Once the investigation concludes, accrual resumes. Emergency claims must meet the same 45-day deadline.

Interaction with Federal Law

Federal claims processing requirements under ERISA apply to self-funded employer plans, which are exempt from Missouri state prompt pay laws. State-regulated health carriers must comply with Missouri law. Medicare and Medicaid have their own claims processing timelines that operate independently of Missouri state law.

Common Questions