11 NCAC 16 .0702             CLAIMS

(a)  When an HMO has been informed that a claim has been incurred, if the date reported is on or before the valuation date, the claim is considered as a reported claim.

(b)  When an HMO has not been informed, on or before the valuation date, concerning a claim that has been incurred on or before the valuation date, the claim is considered as an unreported claim.

(c)  The date on which a claim is determined to be a liability of an HMO is the incurred date.  For example:  The charges for inpatient hospital and physician visits in hospitals would be assigned an incurred date equal to the date of admission; outpatient hospital charges would be assigned an incurred date equal to the date of service; and surgical expenses would be assigned an incurred date equal to the date of the surgery.

 

History Note:        Authority G.S. 58‑2‑40; 58‑67‑135(b);

Eff. February 1, 1995.