The proposed legislation, General Assembly Raised Bill No. 341, aims to amend the current regulations regarding the return of payments made to health care providers by contracting health organizations. Specifically, it reduces the time frame in which these organizations can cancel, deny, or demand the return of payments for authorized covered services from eighteen months to twelve months after the receipt of a clean claim. Exceptions to this rule include instances of suspected fraud, improper billing, duplicate payments, payments that should have been covered by federal or state programs, or payments received from other insurers. Additionally, the bill allows providers one year to resubmit adjusted claims after a payment demand and requires health organizations to provide advance notice of such demands.

The bill also introduces new requirements for health organizations regarding the notification process. They must now send cancellation or payment return notices via certified mail, electronic mail, or facsimile, and include specific details about the amount demanded, the claim in question, and the basis for the demand. Furthermore, if a provider appeals a payment demand, the organization must respond within fifteen business days, or the appeal will be automatically favored for the provider. The legislation emphasizes the establishment of an electronic appeal process and provides a one-year window for providers to identify and file claims with other applicable insurance coverage. The changes are set to take effect on January 1, 2027.