Bill Text: MA H976 | 2009-2010 | 186th General Court | Introduced
Bill Title: Regulate retroactive denials of health insurance claims
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2009-01-20 - Public Hearing date 12/2 at 1:00 PM in Hearing Room A1 [H976 Detail]
Download: Massachusetts-2009-H976-Introduced.html
The Commonwealth of Massachusetts
_______________
PRESENTED BY:
Ronald Mariano
_______________
To the
Honorable Senate and House of Representatives of the Commonwealth of
Massachusetts in General
Court assembled:
The undersigned legislators and/or citizens respectfully petition for the passage of the accompanying bill:
An Act to limit retroactive denials of health insurance claims.
_______________
PETITION OF:
Name: |
District/Address: |
Ronald Mariano |
3rd Norfolk |
[SIMILAR MATTER FILED IN PREVIOUS
SESSION
SEE HOUSE, NO. 3932 OF 2007-2008.]
The Commonwealth of
Massachusetts
_______________
In the Year Two Thousand and Nine
_______________
An Act to limit retroactive denials of health insurance claims.
Be
it enacted by the Senate and House of Representatives in General Court
assembled, and by the authority of the same, as follows:
Section 1. Section 38 of chapter 118E, as appearing in the 2006 Official Edition of the General Laws, is hereby amended by adding the following new paragraph:
In this paragraph, "retroactive denial of a
previously paid claim" means any attempt by the Division to retroactively
collect payments already made to a health care provider with respect to a claim
by requiring repayment of such payments, reducing other payments currently owed
to the provider, withholding or setting off against future payments, or reducing
or affecting the future claim payments to the provider in any other manner. The
Division shall not impose on any health care provider any retroactive denial of
a previously paid claim or any part thereof unless:
(a) The Division has provided the reason
for the retroactive denial in writing to the health care provider; and
(b) The time which has elapsed since the
date of payment of the challenged claim does not exceed 12 months. The
retroactive denial of a previously paid claim may be permitted beyond 12 months
from the date of payment only for the following reasons:
(1) The claim was
submitted fraudulently;
(2) The claim payment
was incorrect because the provider or the insured was already paid for the
health care services identified in the claim;
(3) The health care
services identified in the claim were not delivered by the physician/provider;
(4)
The claim payment is the subject of adjustment with another insurer,
administrator, or payor; or
(5) The claim payment is
the subject of legal action.
The Division shall notify a health care provider at least 15 days in advance of
the imposition of any retroactive denials of previously paid claims. The health
care provider shall have 6 months from the date of notification under this
paragraph to determine whether the insured has other appropriate insurance,
which was in effect on the date of service. Notwithstanding the contractual
terms between the Division and provider, the Division shall allow for the
submission of a claim that was previously denied by another insurer due to the
insured's transfer or termination of coverage.
Section 2. Subsection 4(c) of section 108 of chapter 175, as appearing in the 2006 Official Edition of the General Laws, is hereby amended by adding at the end thereof the following new subsection:
4(d) In this section "retroactive denial of
a previously paid claim" means any attempt by an insurer to retroactively
collect payments already made to a health care provider with respect to a claim
by requiring repayment of such payments, reducing other payments currently owed
to the provider, withholding or setting off against future payments, or
reducing or affecting the future claim payments to the provider in any other
manner.
No insurer shall impose on any health care provider any retroactive denial of a
previously paid claim or any part thereof unless:
(a) The insurer has provided the reason
for the retroactive denial in writing to the health care provider; and
(b) The time which has elapsed since the
date of payment of the challenged claim does not exceed 12 months. The
retroactive denial of a previously paid claim may be permitted beyond 12 months
from the date of payment only for the following reasons:
(1) The claim was
submitted fraudulently;
(2) The claim payment
was incorrect because the provider or the insured was already paid for the
health care services identified in the claim;
(3) The health care
services identified in the claim were not delivered by the physician/provider;
(4) The claim payment
was for services covered by Title XVIII, Title XIX, or Title XXI of the Social
Security Act;
(5) The claim payment is
the subject of adjustment with another insurer, administrator, or payor; or
(6) The claim payment is
the subject of legal action.
An insurer shall notify a health care provider at least 15 days in advance of
the imposition of any retroactive denials of previously paid claims. The health
care provider shall have 6 months from the date of notification under this
paragraph to determine whether the insured has other appropriate insurance,
which was in effect on the date of service. Notwithstanding the contractual
terms between the insurer and provider, the insurer shall allow for the
submission of a claim that was previously denied by another insurer due to the
insured's transfer or termination of coverage.
Section 3. Section 8 of chapter 176A, as appearing in the 2006 Official Edition of the General Laws, is hereby amended by adding at the end thereof the following new clause:
(h) In this section "retroactive denial of a
previously paid claim" means any attempt by a corporation to retroactively
collect payments already made to a health care provider with respect to a claim
by requiring repayment of such payments, reducing other payments currently owed
to the provider, withholding or setting off against future payments, or
reducing or affecting the future claim payments to the provider in any other
manner.
The corporation shall not impose on any health care provider any retroactive
denial of a previously paid claim or any part thereof unless:
(a) The corporation has provided the
reason for the retroactive denial in writing to the health care provider; and
(b) The time which has elapsed since the
date of payment of the challenged claim does not exceed 12 months. The
retroactive denial of a previously paid claim may be permitted beyond 12 months
from the date of payment only for the following reasons:
(1) The claim was
submitted fraudulently;
(2) The claim payment
was incorrect because the provider or the insured was already paid for the
health care services identified in the claim;
(3) The health care
services identified in the claim were not delivered by the physician/provider;
(4) The claim payment
was for services covered by Title XVIII, Title XIX, or Title XXI of the Social
Security Act;
(5) The claim payment is
the subject of adjustment with another insurer, administrator, or payor; or
(6) The claim payment is
the subject of legal action.
A corporation shall notify a health care provider at least 15 days in advance
of the imposition of any retroactive denials of previously paid claims. The
health care provider shall have 6 months from the date of notification under
this paragraph to determine whether the insured has other appropriate
insurance, which was in effect on the date of service. Notwithstanding the
contractual terms between the corporation and provider, the corporation shall
allow for the submission of a claim that was previously denied by another
insurer due to the insured's transfer or termination of coverage.
Section 4. Section 7 of chapter 176B, as appearing in the 2006 Official Edition of the General Laws, is hereby amended by adding at the end thereof the following new paragraph:
In this paragraph "retroactive denial of a previously
paid claim" means any attempt by a corporation to retroactively collect
payments already made to a health care provider with respect to a claim by
requiring repayment of such payments, reducing other payments currently owed to
the provider, withholding or setting off against future payments, or reducing
or affecting the future claim payments to the provider in any other manner.
The corporation shall not impose on any health care provider any retroactive
denial of a previously paid claim or any part thereof unless:
(a) The corporation has provided the reason
for the retroactive denial in writing to the health care provider; and
(b) The time which has elapsed since the
date of payment of the challenged claim does not exceed 12 months. The
retroactive denial of a previously paid claim may be permitted beyond 12 months
from the date of payment only for the following reasons:
(1) The claim was
submitted fraudulently;
(2) The claim payment
was incorrect because the provider or the insured was already paid for the
health care services identified in the claim;
(3) The health care
services identified in the claim were not delivered by the physician/provider;
(4) The claim payment
was for services covered by Title XVIII, Title XIX, or Title XXI of the Social
Security Act;
(5) The claim payment is
the subject of adjustment with another insurer, administrator, or payor; or
(6) The claim payment is
the subject of legal action.
A corporation shall notify a health care provider at least 15 days in advance
of the imposition of any retroactive denials of previously paid claims. The
health care provider shall have 6 months from the date of notification under
this paragraph to determine whether the insured has other appropriate
insurance, which was in effect on the date of service. Notwithstanding the
contractual terms between the corporation and provider, the corporation shall
allow for the submission of a claim that was previously denied by another
insurer due to the insured's transfer or termination of coverage.
Section 5. Section 6 of chapter 176G, as appearing in the 2006 Official Edition of the General Laws, is hereby amended by adding at the end thereof the following new paragraph:
In this paragraph "retroactive denial of a
previously paid claim" means any attempt by a health maintenance
organization to retroactively collect payments already made to a health care
provider with respect to a claim by requiring repayment of such payments,
reducing other payments currently owed to the provider, withholding or setting
off against future payments, or reducing or affecting the future claim payments
to the provider in any other manner.
A health maintenance organization shall not impose on any health care provider
any retroactive denial of a previously paid claim or any part thereof unless:
(a) The health maintenance organization
has provided the reason for the retroactive denial in writing to the health
care provider; and
(b) The time which has elapsed since the
date of payment of the challenged claim does not exceed 12 months. The
retroactive denial of a previously paid claim may be permitted beyond 12 months
from the date of payment only for the following reasons:
(1) The claim was
submitted fraudulently;
(2) The claim payment
was incorrect because the provider or the insured was already paid for the
health care services identified in the claim;
(3) The health care
services identified in the claim were not delivered by the physician/provider;
(4) The claim payment
was for services covered by Title XVIII, Title XIX, or Title XXI of the Social
Security Act;
(5) The claim payment is
the subject of adjustment with another insurer, administrator, or payor; or
(6) The claim payment is
the subject of legal action.
A health maintenance organization shall notify a health care provider at least
15 days in advance of the imposition of any retroactive denials of previously
paid claims. The health care provider shall have 6 months from the date of
notification under this paragraph to determine whether the insured has other
appropriate insurance, which was in effect on the date of service.
Notwithstanding the contractual terms between the health maintenance
organization and provider, the health maintenance organization shall allow for
the submission of a claim that was previously denied by another insurer due to
the insured's transfer or termination of coverage.
Section 6. Section 2 of chapter 176I, as appearing in the 2006 Official Edition of the General Laws, is hereby amended by adding at the end thereof the following new paragraph:
In this paragraph "retroactive denial of a
previously paid claim" means any attempt by an organization to
retroactively collect payments already made to a health care provider with
respect to a claim by requiring repayment of such payments, reducing other
payments currently owed to the provider, withholding or setting off against
future payments, or reducing or affecting the future claim payments to the provider
in any other manner.
An organization shall not impose on any health care provider any retroactive
denial of a previously paid claim or any part thereof unless:
(a) The organization has provided the
reason for the retroactive denial in writing to the health care provider; and
(b) The time which has elapsed since the
date of payment of the challenged claim does not exceed 12 months. The
retroactive denial of a previously paid claim may be permitted beyond 12 months
from the date of payment only for the following reasons:
(1) The claim was
submitted fraudulently;
(2) The claim payment
was incorrect because the provider or the insured was already paid for the
health care services identified in the claim;
(3) The health care
services identified in the claim were not delivered by the physician/provider;
(4) The claim payment
was for services covered by Title XVIII, Title XIX, or Title XXI of the Social
Security Act;
(5) The claim payment is
the subject of adjustment with another insurer, administrator, or payor; or
(6) The claim payment is
the subject of legal action.
An organization shall notify a health care provider at least 15 days in advance
of the imposition of any retroactive denials of previously paid claims. The
health care provider shall have 6 months from the date of notification under
this paragraph to determine whether the insured has other appropriate
insurance, which was in effect on the date of service. Notwithstanding the
contractual terms between an organization and provider, the organization shall
allow for the submission of a claim that was previously denied by another
insurer due to the insured's transfer or termination of coverage.