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State payer laws for billing and patient-access teams

Prompt-pay · recoupment · copay accumulators · gold card · plan-type rules

Three 50-state tables, the gold-card page, and the one page that decides whether any of them apply. Every row is quoted from the state's own statute or regulation and marked Confirmed or Unverified; nothing is paraphrased from a tracker.

Reviewed Sep 20, 2026 · maintained by Erin Rose · general reference, not legal advice

The five references

Self-funded vs fully-insuredThe plan-type test that decides whether any state law below reaches the claim. Read first.Prompt-pay laws by stateClean-claim deadlines and late-payment interest, 51 jurisdictions, 44 confirmed from statute text. With a calculator.Recoupment limits by stateLookback, notice and offset rules, 51 jurisdictions, 38 confirmed from statute text.Copay accumulator laws by state27 jurisdictions require the copay card to count toward the deductible; the generic exceptions; which plans it reaches.Gold-card prior-auth laws by stateThe four states with a real in-force gold card, the framework states, and the lookalikes that are not.

How to use them in a dispute

  1. Plan type first. Every table in this section is state insurance law; 29 U.S.C. §1144 is why it stops at the self-funded line. It reaches fully-insured plans, HMOs and (sometimes) Medicaid managed care; it does not reach self-funded ERISA plans, which cover about 63% of workers with employer coverage. Get this wrong and the state insurance department will tell you it has no jurisdiction — after the appeal window has run.
  2. Quote the section, not the summary. Each state entry carries the operative sentence from the state's own code and a link to it. Paste the sentence and the section into the reconsideration; a payer's provider-relations desk responds to a citation it can look up.
  3. Attach the table of claims. One late claim is a conversation; a spreadsheet of forty clean claims paid past the deadline is a pattern, which is what regulators act on.
  4. Send the next claim clean. The deadline runs from receipt of a clean claim. Claim Check runs the NCCI, MUE and modifier edits before the claim leaves, so the clock starts on the day you sent it.

Frequently asked

Which of these laws apply to a Medicare Advantage plan?
None of the state tables. Medicare Advantage is federally regulated; prompt payment, recoupment and appeals follow 42 CFR Part 422 and the plan's contract. The self-funded page explains the split.
Why are some rows marked Unverified?
Because we could not open the state's own statute text in this cycle — a legislature site that blocks automated access, or a code that is only published through a commercial vendor. The row keeps its citation as a lead and is excluded from any calculation until a person confirms it against the primary text.
How often are the tables re-checked?
The Sources block under each table gives the date the set was last verified against the primary text. We re-verify a row when a reader sends a correction with the section, and sweep the set when a legislative session closes.

Related references

Drug-claim denialsThe ten codes that land on drug lines: reason, fix, appealMUE lookupMax units per day, the edit behind most "not clean" rejectionsReference libraryEvery billing and coverage reference on the site

Hold the payer to the statute — and send the next claim clean

Claim Check runs the NCCI pair, MUE and JW/JZ edits on the drug and administration lines before submission, so the clean-claim date is the date you sent it.

Open Claim Check

Sources & how this is maintained

What this hub is
The index of the site's state-law references. The method for every table is on the table's own page.
Corrections
Send one with the statute section.