On page 1, line 6, of the Introduced bill, after "carrier" insert " only"
On page 1, line 7, of the Introduced bill, after "months " delete "year "
On page 1, line 8, of the Introduced bill, after "This" insert " limitation"
On page 1, line 9, of the Introduced bill, after "that:
(1) Was " insert "determined by the health carrier to have been "
On page 1, line 9, of the Introduced bill, after "fraudulently" insert " or to involve waste or abuse"
On page 2, line 1, of the Introduced bill, after "58." insert "For purposes of this section, "medical services," do not include dental services, pharmaceutical services, or the provision of prescription drug products or supplies.
"
On page 2, line 7, of the Introduced bill, after "58-17H:" delete "A health carrier shall notify a provider, in writing, at least thirty days in advance of retroactively denying a previously paid claim, as defined in section 1 of this Act.
The provider has six months from the date of notification under this section to refund the claim payment at issue, unless the provider determines and notifies the health carrier that an exception set forth in section 1 of this Act is applicable.
The health carrier has thirty days after receipt of the notice to respond in writing to the provider. If the health carrier objects to the provider's determination, the health carrier must state the basis for the objection. If the health carrier fails to respond to the provider's determination within the time required, the matter is deemed to be resolved and the carrier may take no additional action in furtherance of a claim denial."
On page 2, line 17, of the Introduced bill, after "denial." delete "If a dispute between the provider and the health carrier concerning the claim payment at issue persists, either may, within thirty days of the provider's receipt of the health carrier's response to the provider's determination, file with the Division of Insurance a request for a mandatory review of the ongoing claim payment dispute. Upon receipt of all necessary documentation, the division shall provide a recommendation for a resolution. No legal action may be commenced during the pendency of the review.
Within thirty days after the division has submitted its recommendation to the health carrier and the provider, either party may commence legal action for a resolution of the dispute by a court of competent jurisdiction in this state. Nothing in this section preempts or limits any other right or remedy available to a health carrier or provider under law, except to the extent that such right or remedy is inconsistent with this section.
If legal action is not commenced as provided for in this section, the provider must refund the claim payment at issue."
On page 2, line 30, of the Introduced bill, after "carrier" insert ", as provided for in section 1 of this Act,"
On page 2, line 32, of the Introduced bill, delete " health care" and insert " medical "
On page 2, line 32, of the Introduced bill, after "careservices" delete ", as defined in § 58-17H-1, which are"