Bill > H925

This bill aims to prevent health insurance companies and other entities that manage health benefits from retroactively denying claims for mental health and substance abuse services, which means they cannot take back payments already made or reduce future payments for services already rendered, unless specific conditions are met. Generally, such denials are prohibited if less than six months have passed since the claim was submitted and the entity hasn't provided the provider with a clear explanation for the denial and what's needed to fix it. However, retroactive denials can occur after six months if the claim was fraudulent, if it's being adjusted due to expected payment from another insurance provider and less than 12 months have passed since submission, or if the claim is part of a legal action. If a denial is allowed due to another payer's involvement, the provider must be notified 15 days in advance and given six months to sort out secondary insurance payments, and insurers must accept claims previously denied due to a patient switching or losing coverage. The bill also defines "provider" as a licensed mental health or substance use disorder professional. Additionally, it requires the Division of Medical Assistance to develop a process to help providers reconcile claims involving multiple payers for MassHealth enrollees, with a report due by December 31, 2015.