Washington law sets claim deadlines and refund request periods

Carriers must pay or deny clean claims within 30 days and send a detailed notice within 21 days when a claim is not clean. The rules cover regulated health carriers and plans offered through the public and school employees' benefit programs. They cover claims from participating providers and facilities, and from Indian health care providers, including those without contracts. Medicaid managed care plans are excluded. For an incomplete claim, the carrier must make a good faith effort to request all needed information at once and cannot make another request for 30 days. After receiving all requested information, the carrier generally has 30 days to decide the claim. If the provider or facility does not send the information within 21 days of the request, the carrier has 40 days after receiving it. The rules exclude claims with documented evidence of fraud or material misrepresentation and allow relief when listed emergencies or labor disputes cause noncompliance. The rules apply to health plans filed or renewed on or after January 1, 2027.

Carriers must pay interest on claims when they miss required notice or payment deadlines; the insurance commissioner may impose a penalty for some long delays. These duties concern carriers' covered claims and missed notice or payment deadlines. Interest is 1 percent per month for days 1 through 60 after a missed deadline, then 1.5 percent per month until the claim is resolved. Carriers cannot apply the interest to a patient's deductible, copayment, or coinsurance, and must add it to the unpaid claim without requiring another claim. For a claim still unresolved after 90 days, the commissioner may impose a penalty under rules and must consider whether the carrier has a pattern of violations. The stated fraud and emergency exceptions also apply. Interest runs from the missed deadline until the claim is resolved. The possible penalty concerns claims unresolved for more than 90 days.

Carriers may ask providers to repay a claim within 12 months of payment, or within 18 months when coordinating benefits with another payer. These limits cover carriers seeking repayment from health care providers for claims they previously paid. For mental health and substance use disorder services, the respective periods are six months and nine months. These periods do not apply in cases of fraud or the separate rule allowing a request at any time when a legally responsible third party has paid or will pay the provider and the carrier cannot recover directly. A carrier must explain why it believes repayment is owed; a request involving another payer must also name and give the mailing address of the primary payer. The request period runs from the date of the original payment. This section takes effect January 1, 2028.