The bill introduces comprehensive reforms to the insurance claims payment process for healthcare providers, particularly targeting the practice of downcoding by payment adjudicators. It establishes a new section, 627.4193, which prohibits downcoding when services are ordered by in-network providers unless specific conditions are met. Adjudicators must provide detailed explanations for any downcoding, including the original payment amount that would have been made. Additionally, the bill mandates that payment adjudicators maintain clear downcoding policies on their websites and ensures compliance from health insurers. The bill also amends prior authorization processes, requiring timely decisions from utilization review entities and mandating the use of a secure electronic submission process for prior authorization requests.

Further amendments streamline the claims processing timeline, reducing the time for insurers to pay or deny claims from 120 days to 30 days, and establishing that claims must be paid if not contested within specified timeframes. The bill prohibits health insurers from requesting duplicate documents and mandates electronic transmission of claims and payments. It also addresses overpayment claims, requiring written statements for any claims of overpayment and setting strict timelines for contesting such claims. Overall, the bill aims to enhance transparency, reduce delays in patient care, and protect healthcare providers from unjust practices and financial burdens related to claims processing.

Statutes affected:
S 1130 Filed: 627.42392, 627.6131, 641.3155, 395.1065