Bill > AB2431

This bill prohibits health care service plans and insurers from using automated systems or tools to "downcode" medical claims, which means unilaterally changing a submitted service or procedure code to a lower-paying one without proper justification. If a claim is downcoded, the plan or insurer must provide the provider with a clear explanation, including the specific reasons, the coding criteria used, and the original and revised codes and payments. The bill also mandates a clear and accessible process for providers to dispute downcoded claims, with specific timelines for dispute submission and resolution, and allows providers to appeal similar downcoded claims in batches. Furthermore, it prohibits discriminatory downcoding practices against providers who treat complex or chronic conditions, and authorizes state departments to take action against plans or insurers engaging in such practices.

Health and Social Services

https://leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=202520260AB2431