WV HB5379

Insurers must pay clean claims for out-of-network ground ambulance services directly to the emergency medical services agency within 30 days, and cannot send payment to the covered individual instead.

Payment exceptions apply when another party is responsible, benefits are being coordinated with another payor, the provider was already paid, or the claim involves fraud or material misrepresentation.

When a claim is determined not to be clean, insurers must provide written notice within 30 days acknowledging receipt and explaining specific reasons for denial or identifying what additional information is needed.

The requirements apply uniformly across five types of insurance regulated under West Virginia Code: accident and sickness insurance, group accident and sickness insurance, hospital/medical/dental/health service corporations, health care corporations, and health maintenance organizations.