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: ________________________________
According to our records, the enclosed claim has not been paid. Please consider this a demand
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.
Cc: Washington State Medical Association