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 shall be 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 shall be 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 incurred date for charges for inpatient hospital and physician visits in hospital shall be the date of admission, for outpatient hospital charges shall be the date of service, and for surgical expenses shall be the date of the surgery.

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

Eff. February 1, 1995;

Readopted Eff. October 1, 2018.