State RegulationsNC specificDifficulty 2/5
A hospital submits a health claim to an insurer licensed in North Carolina. Within what period after receiving the claim must the insurer pay it, deny it, or request additional information?
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Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
Under G.S. 58-3-225(b), the insurer must pay, deny, or request information within 30 calendar days after receiving a claim, and a claim is presumed received five business days after mailing or electronic transmission. Under G.S. 58-3-225(e), late payments bear interest at 18% per annum, giving insurers a real financial incentive to decide claims promptly.
Why the other options are wrong
- A) Ninety days is the window for the insurer to deny a claim when requested information is not received under G.S. 58-3-225(c), not the initial claim-decision deadline.
- B) Fifteen days is the time an insurer has to furnish claim forms after notice of claim under G.S. 58-51-15(a)(6), not the pay-deny-request deadline.
- C) Sixty days relates to provider claim status reporting under G.S. 58-3-225(g), not the initial decision window.
Memory hook
Thirty days to pay, deny, or ask - then 18% interest if you dawdle.