Bill > H919

This bill aims to prevent insurance companies, referred to as "carriers," from unfairly denying payment for medically necessary healthcare services. It requires carriers to pay for services ordered by a patient's treating healthcare provider if those services are covered by the patient's health plan and follow the carrier's established guidelines for medical review. Crucially, a claim for medically necessary services cannot be denied if the provider followed the carrier's approved procedure for obtaining authorization at the time the service was rendered. The bill also sets limits on when carriers can try to get money back, or "recoup," payments. They generally have twelve months from the original payment date to recoup funds, but this is reduced to ninety days if the patient's eligibility for coverage was retroactively terminated or they were retroactively disenrolled, provided the provider can prove they verified the patient's eligibility using the carrier's approved method at the time of service. Furthermore, carriers cannot recoup payments for services already deemed medically necessary or for services that were previously approved by the carrier or their contractor. If a carrier does seek to recoup funds, they must provide the healthcare provider with written notice explaining the reasons, identifying the specific claims involved, and giving the provider thirty days to dispute the recoupment, with this notice needing to be sent at least thirty days before the recoupment is attempted.