South Carolina law (SC Code §38-59-20) requires health insurers to pay or deny clean insurance claims within 30 days of receipt. Failure to pay triggers 15% annual interest on unpaid claims, enforced by the South Carolina Department of Insurance.
Overview
South Carolina's prompt pay statute establishes a 30-day payment standard for all clean insurance claims, whether submitted electronically or on paper. A clean claim includes all necessary information for processing. When an insurer fails to pay within 30 days, interest accrues at 15% per year from day 31 until payment, making timely filing critical for maximizing claim reimbursement.
The South Carolina Department of Insurance (SCDOI) actively monitors and enforces prompt pay compliance. Repeated violations trigger civil penalties and market conduct examinations.
Key Requirements
- 30-day payment window: Insurers must pay or deny clean claims within 30 days of receipt.
- Electronic and paper claims: Same 30-day deadline applies to both submission methods.
- Clean claim definition: A claim submitted with all required information including diagnosis codes, procedure codes, patient ID, provider credentials, and claim amount.
- Incomplete claims: Insurers must identify deficiencies within 15 business days. The 30-day clock restarts upon resubmission of complete information.
- Interest calculation: 15% annual interest accrues from day 31 on the unpaid claim balance.
Penalties and Enforcement
South Carolina Department of Insurance enforces SC Code §38-59-20 through civil penalties and market conduct reviews. Violations result in:
- Civil penalties assessed per violation.
- Market conduct examination by SCDOI.
- Mandatory corrective action plans.
- Public enforcement records and reputational impact.
Appeals and Dispute Resolution
When claims are not paid timely:
- Send a written demand to the insurer citing SC Code §38-59-20 and requesting payment plus accrued interest.
- File a complaint with the South Carolina Department of Insurance if the demand is not met within 15 business days.
- Pursue civil action in South Carolina courts if necessary.
Federal Law and Coordination
South Carolina's state timely filing law coordinates with federal prompt pay rules for Medicare and Medicaid. Medicare claims follow federal Medicare Claims Processing Manual standards (expedited payment), while Medicaid claims comply with South Carolina Medicaid prompt pay rules. When federal and state standards differ, the more favorable deadline applies.
Common Questions
What annual interest does South Carolina impose on late claim payments?
South Carolina imposes 15% annual interest on claims not paid within 30 days. Interest accrues from day 31 until the claim is paid and is calculated on the full unpaid claim amount.
How does SC handle incomplete claims under prompt pay law?
Insurers must notify providers of deficiencies within 15 business days of receipt. Once the provider resubmits the complete claim, a new 30-day payment period begins.
Where do I file a prompt pay complaint with South Carolina Department of Insurance?
File complaints at the South Carolina Department of Insurance website or contact SCDOI directly. Include the claim number, submission date, provider information, and documentation of non-payment.
Do South Carolina's prompt pay rules apply to both electronic and paper claims?
Yes. SC Code §38-59-20 applies the same 30-day payment deadline to both electronic claims and claims submitted by mail.
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Key Statutes
- SC Code §38-59-20: Prompt payment of claims.
- Regulation 69-50: South Carolina Department of Insurance rules on prompt pay requirements.