Plain English Breakdown
The effective date of the law is not provided in the source material.
Rules Against Changing Medical Claim Codes
This law stops health plans from using computers to lower payment amounts on medical claims without a human review of the patient's records.
What This Bill Does
- Prohibits health insurers and service plans from using automated tools or systems to downcode medical claims.
- Requires a documented review of clinical information before changing a claim code to result in lower payment.
- Mandates that insurers give providers specific details and an easy way to dispute if they change a claim code.
- Bans targeting doctors who treat patients with complex, chronic, or severe conditions for downcoding practices.
- Allows state departments to take action against plans found using discriminatory downcoding patterns.
Who It Names or Affects
- Health care service plans regulated by the Department of Managed Health Care
- Health insurers issuing group or individual policies regulated by the Department of Insurance
- Physicians and other health care providers who bill for services
Terms To Know
- Downcoding
- When a payer changes a service code on a claim to one that results in lower payment.
- Automated process
- A computer system or tool used without human review to make decisions about claims.
Limits and Unknowns
- The bill does not specify the exact date it will take effect.
- Specific details on how to dispute a claim are mentioned as requirements but not fully described in this summary.