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deductibles provided for under the customer's benefit contract) and will not discriminate against <br />any customer based on the failure to pay such a fee. <br />4. The following provisions are added to the end of the section and do not replace section <br />"What we will do" of the agreement: <br />A. Prompt Payment of Claims. For claims governed by Washington law, we or the <br />participating entity, as applicable, shall pay or deny claims in accordance with the claims <br />payment standards contained in WAC 284-170-431 which are set forth below. <br />(a) (i) For covered health care services provided to enrolled participants, we or the <br />participating entity shall pay you as soon as practical but subject to the following <br />minimum standards: <br />(A) Ninety-five percent of the monthly volume of clean claims shall be paid within <br />thirty days of receipt by us or our agent; and <br />(B) Ninety-five percent of the monthly volume of all claims shall be paid or denied <br />within sixty days of receipt by us or our agent, except as agreed to in writing by <br />the parties on a claim -by -claim basis. <br />(ii) The receipt date of a claim is the date we or our agent receives either written or <br />electronic notice of the claim. <br />(iii) We shall establish a reasonable method for confirming receipt of claims and <br />responding to your inquiries about claims. <br />(iv) If we or the participating entity fails to pay claims within the standard established <br />under subsection (a) of this section, we or the participating entity shall pay interest on <br />undenied and unpaid clean claims more than sixty-one days old until the standard <br />under subsection (a) of this section is met. Interest shall be assessed at the rate of one <br />percent per month, and shall be calculated monthly as simple interest prorated for any <br />portion of a month. Interest shall be added payable to the amount of the unpaid claim <br />without the necessity of you submitting an additional claim. Any interest paid under <br />this section shall not be applied to an enrolled participant's deductible, copayment, <br />coinsurance, or any similar obligation of the enrolled participant. <br />(v) When payment is issued in both your name and the enrolled participant's name, claim <br />checks shall be made payable in your name first and the enrolled participant second. <br />(b) For purposes of this section, "clean claim" means a claim that has no defect or <br />impropriety, including any lack of any required substantiating documentation, <br />or particular circumstances requiring special treatment that prevents timely <br />payments from being made on the claim under this section. <br />(e) Denial of a claim must be communicated to you and must include the specific <br />reason why the claim was denied. If the denial is based upon medical necessity <br />or similar grounds, then we, upon your request, must also promptly disclose the <br />supporting basis for the decision. <br />(d) We shall be responsible for ensuring that any person acting on our behalf or at <br />our direction or acting pursuant to our standards or requirements complies with <br />these billing and claim payment standards. <br />(e) These standards do not apply to claims about which there is substantial <br />evidence of fraud or misrepresentation by you or enrolled participants, or <br />U11C/SMGA.REGAPX 09.24. WA -22- <br />