36-3411. Behavioral health services; timely reimbursement; penalties

A. The administration shall ensure that behavioral health service providers are reimbursed within ninety days after the service provider submits a clean claim to a regional behavioral health authority.

B. Any contract issued by or on behalf of the administration for the provision of behavioral health services shall include language outlining provisions for penalties for noncompliance with contract requirements.

C. If the regional behavioral health authority does not reimburse a provider as required by this section, the director shall subject the regional behavioral health authority to the penalty provisions prescribed in the contract, which shall not exceed the interest charges prescribed in section 44-1201. The director shall impose any financial penalties levied on the regional behavioral health authority through a reduction in the amount of monies payable to the regional behavioral health authority for administrative expenses.

D. The ninety-day deadline imposed by this section is suspended while a formal grievance regarding the legitimacy of a claim is pending.

E. The administration or a regional behavioral health authority shall not pay claims for covered services that are initially submitted more than nine months after the date of the services for which payment is claimed or that are submitted as clean claims more than twelve months after the date of service for which payment is claimed. A person who is dissatisfied with the denial of a claim by the administration or by the regional behavioral health authority has twelve months from the date of the service for which payment is claimed to institute a grievance against the administration or regional behavioral health authority.

F. For claims paid by the administration, either directly or through a third-party payor, the director may impose a penalty on a regional behavioral health authority or a service provider who submits a claim to the administration for payment more than one time after the same claim had been previously denied by the administration without having attempted to address the reason given for the denial. The penalty imposed by the director shall not exceed the average cost incurred by the administration for processing a claim and shall be levied on the regional behavioral health authority or service provider through reducing any future payment or payments until the amount of the penalty has been paid.

G. This section does not apply to services provided by a hospital pursuant to section 36-2903.01, subsection G, or section 36-2904, subsection H or I.