Bill > SB797

This bill establishes new regulations for how insurers, nonprofit health service plans, and health maintenance organizations (HMOs) handle claims for reimbursement, particularly when they intend to "downcode" a claim, which means altering the service code submitted by a healthcare provider to a lower level, resulting in a reduced payment. The bill prohibits these entities from downcoding claims without reviewing the provider's clinical documentation, basing the decision solely on the diagnosis code, or downcoding emergency services based on the final diagnosis instead of the initial symptoms. It also prevents them from targeting providers who treat complex or chronic conditions. If an insurer intends to downcode a claim, they must notify the healthcare provider within 30 days, explaining the specific reasons, providing the original and revised codes with corresponding payment amounts, and informing the provider of their right to respond with additional documentation within 90 days. The final decision to downcode must be made by a physician qualified in the relevant specialty. Furthermore, insurers must report quarterly on the number of claims they intend to downcode and the number of claims actually downcoded. The bill also clarifies that a final decision to downcode a claim constitutes a coverage decision that a healthcare provider can appeal directly to the Commissioner without first appealing to the insurer, especially if the decision is a result of downcoding. This legislation aims to ensure fair reimbursement practices for healthcare providers and protect patients by preventing arbitrary reductions in claim payments.