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Substitute House Bill No. 5377
Public Act No. 26-56
AN ACT CONCERNING RETURN OF HEALTH CARE PROVIDER
PAYMENTS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Subsection (c) of section 38a-479b of the general statutes is
repealed and the following is substituted in lieu thereof (Effective January
1, 2027):
(c) (1) No contracting health organization shall cancel, deny or
demand the return of full or partial payment for an authorized covered
service due to administrative or eligibility error, more than [eighteen]
twelve months after the date of the receipt of a clean claim, except if:
(A) Such organization has a documented basis to believe that such
claim was submitted fraudulently by such provider;
(B) The provider did not bill appropriately for such claim based on
the documentation or evidence of what medical service was actually
provided;
(C) Such organization has paid the provider for such claim more than
once;
(D) Such organization paid a claim that should have been or was paid
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by a federal or state program; or
(E) The provider received payment for such claim from a different
insurer, payor or administrator through coordination of benefits or
subrogation, or due to coverage under an automobile insurance or
workers' compensation policy. Such provider shall have one ye ar after
the date of the cancellation, denial or return of full or partial payment to
resubmit an adjusted secondary payor claim with such organization on
a secondary payor basis, regardless of such organization's timely filing
requirements.
(2) (A) Such organization shall give at least thirty days' advance
notice to a provider by [mail, electronic mail or facsimile] certified mail,
return receipt requested, electronic mail to such electronic mail address
designated by such provider or facsimile, or through a secure electronic
provider portal or electronic clearinghouse used for claims or remittance
communications, of the organization's cancellation, denial or demand
for the return of full or partial payment pursuant to subdivision (1) of
this subsection.
(B) If such organization demands the return of full or partial payment
from a provider, the notice required under subparagraph (A) of this
subdivision shall disclose to the provider (i) the amount that is
demanded to be returned, (ii) the claim that is the sub ject of such
demand, and (iii) the basis on which such return is being demanded.
(C) Not later than thirty days after the receipt of the notice required
under subparagraph (A) of this subdivision, a provider may appeal such
cancellation, denial or demand in accordance with the procedures
provided by such organization , which shall include, but need not be
limited to, an electronic appeal process. If any such organization fails to
notify the provider of such organization's determination of such appeal
not later than thirty business days after receipt of such appeal from such
provider, such appeal shall be construed in favor of such provider. Any
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demand for the return of full or partial payment shall be stayed during
the pendency of such appeal.
(D) If there is no appeal or an appeal is denied, such provider may
resubmit an adjusted claim, if applicable, to such organization, not later
than thirty days after the receipt of the notice required under
subparagraph (A) of this subdivision or the denial of the appeal,
whichever is applicable, except that if a return of payment was
demanded pursuant to subparagraph (C) of subdivision (1) of this
subsection, such claim shall not be resubmitted.
(E) A provider shall have one year after the date of the written notice
set forth in subparagraph (A) of this subdivision to identify any other
appropriate insurance coverage applicable on the date of service and to
file a claim with such insurer, health care center or other issuing entity,
regardless of such insurer's, health care center's or other issuing entity's
timely filing requirements.
Sec. 2. (NEW) ( Effective January 1, 2027 ) (a) For the purposes of this
section, "health care provider" has the same meaning as provided in
section 38a-477aa of the general statutes.
(b) (1) No insurer, health care center, fraternal benefit society,
hospital service corporation, medical service corporation or other entity
delivering, issuing for delivery, renewing, amending or continuing an
individual or group health insurance policy i n this state on or after
January 1, 2027, providing coverage of the type specified in subdivisions
(1), (2), (4), (11) and (12) of section 38a -469 of the general statutes, shall
cancel, deny or demand the return of full or partial payment for an
authorized covered service due to administrative or eligibility error,
more than twelve months after the date of the receipt of a clean claim
for such service, except if:
(A) Such insurer, center, society, corporation or other entity has a
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documented basis to believe that such claim was submitted fraudulently
by such health care provider;
(B) The health care provider did not bill appropriately for such claim
based on the documentation or evidence of what medical service was
actually provided;
(C) Such insurer, center, society, corporation or other entity has paid
the health care provider for such claim more than once;
(D) Such insurer, center, society, corporation or other entity paid a
claim that should have been or was paid by a federal or state program;
or
(E) The health care provider received payment for such claim from a
different insurer, payor or administrator through coordination of
benefits or subrogation, or due to coverage under an automobile
insurance or workers' compensation policy. Such health care pr ovider
shall have one year after the date of the cancellation, denial or return of
full or partial payment to resubmit an adjusted secondary payor claim
with such organization on a secondary payor basis, regardless of such
insurer's, center's, society' s, corporation's or other entity's timely filing
requirements.
(2) (A) Such insurer, center, society, corporation or other entity shall
give at least thirty days' advance notice to a health care provider by
certified mail, return receipt requested, electronic mail to such electronic
mail address designated by such health care provider or facsimile, or
through a secure electronic health care provider portal or electronic
clearinghouse used for claims or remittance communications, of the
insurer's, center's, society's, corporation's or other entity's cancellation,
denial or demand for the return of full or partial payment pursuant to
subdivision (1) of this subsection.
(B) If such insurer, center, society, corporation or other entity
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demands the return of full or partial payment from a health care
provider, the notice required under subparagraph (A) of this
subdivision shall disclose to the health care provider (i) the amount that
is demanded to be returned, (ii) the claim that is the subject of such
demand, and (iii) the basis on which such return is being demanded.
(C) Not later than thirty days after the receipt of the notice required
under subparagraph (A) of this subdivision, a health care provider may
appeal such cancellation, denial or demand in accordance with the
procedures provided by such insurer, center, societ y, corporation or
other entity, which shall include, but need not be limited to, an
electronic appeal process. If any such insurer, center, society,
corporation or other entity fails to notify the health care provider of such
insurer's, center's, society's, corporation's or other entity's determination
of such appeal not later than thirty business days after receipt of such
appeal from such health care provider, such appeal shall be construed
in favor of such health care provider. Any demand for the return of full
or partial payment shall be stayed during the pendency of such appeal.
(D) If there is no appeal or an appeal is denied, such health care
provider may resubmit an adjusted claim, if applicable, to such insurer,
center, society, corporation or other entity, not later than thirty days
after the receipt of the notice required under subparagraph (A) of this
subdivision or the denial of the appeal, whichever is applicable, except
that if a return of payment was demanded pursuant to subparagraph
(C) of subdivision (1) of this subsection, such claim shall not be
resubmitted.
(E) A health care provider shall have one year after the date of the
written notice set forth in subparagraph (A) of this subdivision to
identify any other appropriate insurance coverage applicable on the
date of service and to file a claim with such insurer, center, society,
corporation or other issuing entity, regardless of such insurer's, center's,
society's, corporation's or other issuing entity's timely filing
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requirements.