Purpose of the Bill

This bill aims to regulate the timelines and processes health insurance companies use when adjusting or recouping payments made to healthcare providers. The goal is to establish clear deadlines and requirements for these financial transactions to ensure accountability and transparency.

Main Provisions

• Adjustment and Recoupment Deadlines: The bill specifies that once a clean claim is paid, adjustments or recoupments of payments by health plan companies and third-party administrators must occur within six months. For cases involving coordination of benefits, subrogation, duplicate claims, retroactive terminations, and instances of fraud and abuse, the deadline remains at 12 months.
• Exemptions: The rules do not apply to pharmacy contracts or payments related to fraud and abuse.
• Written Statement Requirement: Health plan companies or third-party administrators must provide a written statement to healthcare providers when adjusting or recouping payments under coordination of benefits. This statement must explain the grounds for the action and include contact information for the entity responsible for payment.
• Provider Response Time: Healthcare providers have 180 days to submit claims for reimbursement following a payment adjustment or recoupment, unless a longer period is allowed by the payer.

Significant Changes to Existing Law

• The bill proposes reducing the general timeframe for adjusting or recouping payments from 12 months to six months, except in specified circumstances.
• It introduces a requirement for health plan companies to provide detailed written communication when recouping payments, enhancing transparency and provider ability to address issues.

Relevant Terms

health insurance, claim adjustment timeline, recoupment, health care provider reimbursement, coordination of benefits, fraud and abuse, pharmacy contracts, written statement requirements, subrogation, duplicate claims, retroactive terminations.