Payment deadlines
- Electronic claims
- 30 days (submitted electronically)
- Paper claims
- 40 days (submitted manually)
An insurer must pay or deny a clean claim within 40 days of receipt if submitted manually and within 30 days if submitted electronically, with five statutory exceptions: another payor or party is responsible, benefits are being coordinated, the provider has already been paid, the claim was submitted fraudulently, or there was a material misrepresentation. Non-clean claims run on a separate 30-day information-request and adjudication track, and a failure caused materially by the submitter — or by force majeure — is excused. These duties are contract terms: every provider contract entered into, amended, extended, or renewed on or after August 1, 2001 must contain them.
Interest and penalties
"Interest, at a rate of 10 percent per annum, accruing after the 40-day period provided in §33-45-2(a)(1) of this code owing or accruing on any claim under any provider contract or under any applicable law, shall be paid and accompanied by an explanation of the assessment on each claim of interest paid, without necessity of demand, at the time the claim is paid or within 30 days thereafter" (§33-45-2(a)(4)). Read that carefully before quoting it: the accrual trigger is the 40-day period for every claim, including electronic ones. West Virginia also gives providers an express private right of action — §33-45-3 entitles a provider who suffers loss from a violation to "initiate an action to recover actual damages." Actual damages only: despite the section heading, the operative text contains no attorney-fee or cost-shifting language.
Does it apply to dental? Dental expressly covered
Covered. The duty attaches to claims "for health care services rendered pursuant to a provider contract," health care services means items or services furnished to any individual for preventing, alleviating, curing, or healing human illness, injury, or physical or mental disability, and "provider" means a person or entity holding a valid licence or permit under chapter 30 of the code — where dentists are licensed. The scope limit is the payer side: "health plan" excludes Medicare, Medicaid, CHAMPUS, FEHB, PEIA, accident-only, credit, disability, long-term care, Medicare supplement, workers' compensation, and article-16E limited-benefit policies, so this is a commercial provider-contract rule, not a government-program rule.
Self-funded (ERISA) plans: A self-funded private-employer (ERISA) dental plan is generally beyond a state prompt-pay statute's reach: 29 U.S.C. § 1144(b)(2)(B) bars a state from deeming such a plan an insurer, and the courts have read that to keep state insurance regulation off it. The statute itself never uses the words self-funded or prompt pay, and the rule is not categorical — a self-funded governmental or church plan is not an ERISA plan at all, so state law can reach it; § 1144(b)(6) leaves multiple employer welfare arrangements open to state insurance law; and nothing in § 1144 addresses state enforcement against the third-party administrator or the network contract. Where the plan is a self-funded ERISA group health plan, the federal claims-procedure deadlines apply instead: a post-service benefit determination within 30 days (one 15-day extension), at least 180 days to appeal, and an appeal decision within 60 days (or two 30-day levels), under 29 CFR 2560.503-1.
