PROMPT PAYMENT REQUEST LETTER

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					                      PROMPT PAYMENT REQUEST LETTER


Today’s date:          ___________________________

Doctor’s Name:         ___________________________

Practice Name:         ___________________________            Phone: ______________________

Contact Person:        ___________________________            Fax:   ______________________

Address:               ___________________________            E-mail: ______________________

                       ___________________________

                       ___________________________

Patient Name: _________________________________

ID Number:      _________________________________

Claim Number: ________________________________
(if known)


According to our records, the enclosed claim has not been paid. Please consider this a demand
for payment.

Washington State Administrative Code (WAC) 284-43-321 requires that 95% of clean claims to
be paid within 30 days of receipt and that all claims must be paid or denied within 61 days of
receipt. Our records indicate that this claim was received by your organization. To date,
however, this claim has neither been denied nor contested.

This WAC requires that overdue payment for a clean claim bears simple interest at the rate of
12% per year. Interest on overdue payment for a clean claim or for any uncontested portion of a
clean claim begins to accrue on the date the claim should have been paid. Interest is payable
with the payment of the claim.

Therefore, as payment has not been received on this claim within the required timeframe, your
organization is now required to pay the amount of this claim, plus accrued interest at the rate of
12% per year. Please remit payment immediately to the address above.

Sincerely,




Enclosure(s)
Cc:    Washington State Medical Association