Bill > AB52

This bill revises provisions relating to the payment of health insurance claims, creating more uniform and stringent requirements for health insurers, administrators, and other health care organizations. The bill mandates that health carriers must approve or deny claims within specific timeframes - 21 days for electronically submitted claims and 30 days for paper claims - and pay approved claims within the same timeframes. If claims are not paid on time, carriers must pay 10% interest per annum. Additionally, the bill requires health carriers to provide detailed explanations when denying claims, including specific reasons for denial, the criteria used to make the decision, and information about how to challenge the denial. The bill extends these requirements to various types of health care organizations, including health maintenance organizations, fraternal benefit societies, and organizations for dental care. Health carriers must also establish efficient processes for providers to challenge claim denials and submit annual reports to the Insurance Commissioner about their claim processing performance. The bill includes administrative penalties for non-compliance, such as fines and potential suspension or revocation of an organization's certificate of authority. Notably, the bill exempts certain programs like Medicaid, the Children's Health Insurance Program, and the Public Employees' Benefits Program from these new requirements. The provisions will take effect on January 1, 2026, and will apply to policy renewals and claims submitted on or after that date.