Federal Prompt Payment
42 CFR 422.520 - Prompt payment by M+C organization
Contracts between CMS and the M+C organization. The contract between CMS and the M+C organization must provide that the M+C organization will pay 95 percent of the "clean claims" within 30 days of receipt if they are submitted by, or on behalf of, an enrollee of an M+C private fee-for-service plan or are claims for services that are not furnished under a written agreement between the organization and the provider.
The M+C organization must pay interest on clean claims that are not paid within 30 days in accordance with sections 1816(c)(2)(B) and 1842(c)(2)(B).
All other claims must be paid or denied within 60 calendar days from the date of the request.
Contracts between M+C organizations and providers and suppliers. Contracts or other written agreements between M+C organizations and providers must contain a prompt payment provision, the terms of which are developed and agreed to by both the M+C organization and the relevant provider.
Failure to comply. If CMS determines, after giving notice and opportunity for hearing, that an M+C organization has failed to make payments in accordance with paragraph (a) of this section, CMS may provide --
(1) For direct payment of the sums owed to providers, or M+C private fee-for-service plan enrollees; and
(2) For appropriate reduction in the amounts that would otherwise be paid to the organization, to reflect the amounts of the direct payments and the cost of making those payments.
*"Clean claim" means -- (1) A claim that has no defect, impropriety, lack of any required substantiating documentation (consistent with Sec. 422.257(d)) or particular circumstance requiring special treatment that prevents timely payment; and (2) A claim that otherwise conforms to the clean claim requirements for equivalent claims under original Medicare.
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