claims denial; prior authorization; reporting
What changed between versions
Added a specific definition for 'downcode' to clarify that it refers to unilateral alterations of service codes resulting in lower payments.
Expanded reporting requirements to include data on partial vs. complete denials, downcoding incidents, and specific appeal levels for both claims and prior authorizations.
Added new reporting metrics for prior authorization practices, including average and median processing times for standard and expedited requests.
Created a new requirement for a stakeholders meeting in 2032 to evaluate the quality and usefulness of the data collected under the new reporting sections.
Added a new subsection requiring insurers to accept claims sent to original addresses for 90 days after a location change and to notify providers of such changes.
Added a new provision allowing providers to collect monies for services not covered by insurance or denied due to frequency limits, limited to the provider's fee schedule.
Changed the retroactive effective date for payment rules from June 30, 2026, to August 1, 2026, and added a new reporting deadline of August 1 for grievance summaries.
Added a provision stating that claim adjustments or denials cannot be made more than one year after the original payment or denial, with exceptions for fraud.
