Laserfiche WebLink
instances where we have not been granted reasonable access to information <br />under your control. <br />(f) You and we are not required to comply with this section if the failure to comply <br />is occasioned by any act of God, bankruptcy, act of a governmental authority <br />responding to an act of God or other emergency, or the result of a strike, <br />lockout, or other labor dispute. <br />B. Payment of Claims Involving Coordination of Benefits. We or the participating entity <br />shall not unreasonably delay payment of a claim by reason of the application of a <br />coordination of benefits provision. Payment of a claim involving the application of a <br />coordination of benefit provision shall be made 30 days after receipt of the claim. When <br />payment of a claim is necessarily delayed for reasons other than the application of a <br />coordination of benefits provision, investigation of other plan coverage shall be conducted <br />concurrently, so as to create no further delay in the ultimate payment of benefits. If we or <br />the participating entity is required by the above stated time limit to make payment as the <br />primary plan, and we or the participating entity is not the primary plan, we or the <br />participating entity may exercise its rights of recovery under the agreement between you <br />and us to recover any excess payments made thereby. <br />C. Enrolled Participants Contracting Outside the Health Care Plan. Notwithstanding any <br />other provision of law, we, when subject to the jurisdiction of the state of Washington as a <br />health carrier, may not prohibit, directly or indirectly, enrolled participants from freely <br />contracting at any time to obtain any health care services outside the health care plan on any <br />terms or conditions enrolled participant chooses. Nothing in this section shall be construed <br />to bind us for any services delivered outside the health plan. <br />D. Retrospective Denial. In the event we offer a health care plan that is governed by RCW <br />48.43.525 or WAC 284-43-2000(4), we will comply with the applicable retrospective claim <br />denial requirements as set forth in RCW 48.43.525 and WAC 284-43-2000(4). <br />E. Refunds and Additional Payment. Additionally, in the event we offer a health care plan <br />that is governed by RCW 48.43, and only if you are a "health care provider" as that term is <br />defined in RCW 48.43.005. <br />(a) Our Requests for a Refund. Except in cases of fraud or as otherwise provided in this <br />section and RCW 48.43.600, All requests for refunds must be made by us in writing <br />within twenty-four (24) months after the date that the payment was made; (ii) <br />Requests for refunds that relate to coordination of benefits must be made within thirty <br />(30) months after the date that the payment was made; and (iii) We may not request a <br />contested refund to be paid any sooner than six (6) months after receipt of the request. <br />Requests for refunds must specify why we believe you owe the refund. Requests for a <br />refund that involve coordination of benefits must include the name and mailing <br />address of the entity that has primary responsibility for payment of the claim. If you <br />do not contest the request in writing to us within thirty (30) days of its receipt, the <br />request is deemed accepted and the refund must be paid. <br />We may at any time request a refund from you of a payment previously made to satisfy a claim <br />if. (A) a third party, including a government entity, is found responsible for satisfaction of the <br />claim as a consequence of liability imposed by law, such as tort liability; and (13) we are unable <br />to recover directly from the third party because the third party has either already paid or will pay <br />you for the health services covered by the claim. <br />UHC/SMGA.REGAPX.09.24.WA -23- <br />