The proposed bill, titled "An Act to prevent inappropriate denials by insurers for medically necessary services," aims to enhance protections for patients and healthcare providers regarding insurance claims for medically necessary services. It amends Section 24B of chapter 175 of the General Laws by introducing several key provisions. These include requirements for insurers (carriers) to pay for healthcare services ordered by treating providers if the services are covered and follow the carrier's clinical review criteria. Additionally, claims for medically necessary services cannot be denied based on administrative or technical defects unless there is evidence of fraudulent submission. The bill also establishes a twelve-month limit for carriers to recoup payments and outlines specific conditions under which recoupments cannot occur, such as when a provider has verified an insured's eligibility at the time of service.

Furthermore, the bill mandates that carriers provide written notice to healthcare providers detailing the reasons for any recoupment and allows providers to challenge these requests. If a claim is denied due to an unintentional error in authorization, the provider can appeal, and the carrier must conduct a retrospective review within thirty days. If the service is deemed medically necessary, the carrier is required to reverse the denial and pay the claim. The bill also tasks the commissioner of insurance with promulgating regulations to enforce these provisions within ninety days of the bill's effective date, ensuring that the new rules apply to provider contracts entered into, renewed, or amended thereafter.

Statutes affected:
Bill Text: 175-24B