Bill Summary – FastDemocracy

APPROVED                 CHAPTER
                                                                 JUNE 17, 2021                 272
                                                                BY GOVERNOR              PUBLIC LAW
                                 STATE OF MAINE
                                          _____
                          IN THE YEAR OF OUR LORD
                        TWO THOUSAND TWENTY-ONE
                                          _____
                                  S.P. 423 - L.D. 1317
An Act To Regulate Insurance Carrier Practice or Facility-wide Prepayment
                                Review
Be it enacted by the People of the State of Maine as follows:
    Sec. 1. 24-A MRSA §4303, sub-§24 is enacted to read:
    24. Practice or facility-wide prepayment review of providers. A practice or
facility-wide prepayment review of the documentation or records of a provider conducted
by a carrier for the purposes of identifying fraud, waste or abuse, determining whether the
documentation is appropriate or adequate to support a claim for covered health care
services or determining whether health care services are or were medically necessary health
care as a condition of payment must be conducted in accordance with the following
requirements.
    A. When a carrier subjects a provider or facility to a practice or facility-wide
    prepayment review, the carrier shall provide a process to allow claims and
    documentation to be submitted to the carrier electronically for purposes of proving
    timely filing and tracking the carrier's compliance with time limits in other applicable
    laws.
    B. Claims subject to a practice or facility-wide prepayment review must be paid or
    disputed within 30 days as required by section 2436. Any claim that is not disputed
    pursuant to section 2436 or paid within 30 days by the carrier is overdue and subject to
    interest in accordance with section 2436.
    C. Any records of an enrollee reviewed as part of a practice or facility-wide
    prepayment review must be reviewed by the same reviewer to the extent possible. The
    reviewer who performs the practice or facility-wide prepayment review is the primary
    contact person for the provider related to an audit, review, denial or nonpayment of a
    claim. Any practice or facility-wide prepayment review that involves clinical or
    professional judgement must be conducted by or in consultation with a clinical peer.
    D. A carrier may not apply additional or different documentation standards beyond the
    standards set by the professional association of the provider subject to practice or
    facility-wide prepayment review if those standards are publicly available or made
                                   Page 1 - 130LR1497(03)
    available to the carrier. This paragraph does not prohibit carriers from establishing or
    applying medical policies or clinical guidelines to determine whether a service is a
    covered benefit and medically necessary health care. This paragraph does not apply to
    claims submitted by a hospital or other health care facility.
    E. A carrier may not deny payment of a claim for covered health care services by a
    provider solely on the basis of a minor documentation error or omission, including, but
    not limited to, misspelling, use of an abbreviation or a correctable error, unless the
    carrier affords the provider or enrollee the opportunity to resubmit the claim to correct
    the identified error.
    F. If a carrier requires additional information as part of a practice or facility-wide
    prepayment review of a claim for covered health care services by a provider, the carrier
    shall inform the provider with reasonable specificity of the information needed by the
    carrier to adjudicate the claim.
    G. Additional information required by a carrier is considered timely filed by the
    provider if submitted within 30 days from the date the provider received notice from
    the carrier of the errors, omissions or additional information needed.
    H. A carrier shall provide information on how a provider may appeal the denial of a
    claim, including the mailing or e-mail address or fax number where an appeal should
    be sent, on its publicly accessible website or in a provider manual.
    I. A carrier shall provide an opportunity to appeal the results of an audit leading to the
    provider being put on a practice or facility-wide prepayment review.
    J. A carrier may not audit a provider or require that a provider's claims be subject to
    practice or facility-wide prepayment review as retribution for raising contract disputes.
For the purposes of this subsection, "practice or facility-wide prepayment review" means a
manual review or audit process of all, or substantially all, of a provider's claims by a carrier
or the carrier's agent.
     Sec. 2. Application. This Act applies to any claim that has been subjected to practice
or facility-wide prepayment review as described in the Maine Revised Statutes, Title 24-A,
section 4303, subsection 24 that has not yet been resolved as of the effective date of this
Act and to any claim submitted by a provider on or after the effective date of this Act.
                                     Page 2 - 130LR1497(03)