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Time frames associated with the prompt payment of claims
Section 3901.381 of the Revised Code establishes various time frames for the processing and payment of claims. The time frames vary depending upon the circumstances.
- A third-party payer has fifteen (15) days from receipt to notify a provider when a materially deficient claim is received. Examples of materially deficient claims include claims with an incorrect patient name or benefit contracts number, a patient that cannot be identified, a claim without as or treatment code or a claim without a provider's identifying number. The fifteen (15) day time period and the time spent correcting the deficiencies do not count toward the calculation of time in which a claim must be processed.
- A third-party payer has thirty (30) days to process a claim if no supporting documentation is needed.
- A third-party payer has forty-five (45) days to process a claim if the third-party payer requests additional supporting documentation. However, third-party payers must request supporting documentation within thirty (30) days of the initial receipt of the claim. The time period of forty-five (45) days is suspended until the third-party payer receives the last piece of information requested in the initial thirty (30) day period.
- The time period is not suspended if a third-party payer requests additional supporting documentation after receiving initially requested information.
- A request for additional supporting documentation that is made outside the thirty (30) day time period and that is based on information received in the initial request regarding a previously unknown pre-existing condition may suspend the forty-five (45) day processing time.
- A third-party payer may refuse to process a claim submitted by a provider if the provider submits the claim later than forty-five (45) days after receiving notice from a different third-party payer or a state or federal program that that payer or program is not responsible for the cost of the health care services, or if the provider does not submit the notice of denial from the different third-party payer or program with the claim.
- A third-party payer that has a timely filing requirement must process an untimely claim if all the following apply:
- The claim was initially submitted to a different third-party payer or state or federal program;
- The provider submits the claim to the second payer within forty-five (45) days of receiving notice that the first payer denied the claim; and
- The provider submits the notice of denial along with the claim.
- When a claim is submitted later than one year after the last date of service for which reimbursement is sought, a third-party payer shall pay or deny the claim not later than ninety (90) days after receipt of the claim or, alternatively, pursuant to the requirements of sections 3901.381 to 3901.388 of the Revised Code.