LAW WITHOUT
GOVERNOR'S CHAPTER
SIGNATURE
574
MARCH 26, 2024 PUBLIC LAW
STATE OF MAINE
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IN THE YEAR OF OUR LORD
TWO THOUSAND TWENTY-FOUR
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H.P. 903 - L.D. 1407
An Act to Amend the Maine Insurance Code Regarding Payments by Health
Insurance Carriers to Providers
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §4303, sub-§9, as amended by PL 2021, c. 311, §1, is further
amended to read:
9. Notice of amendments to provider agreements. A carrier offering or renewing a
health plan in this State shall notify a participating provider of a proposed amendment to a
provider agreement at least 60 days prior to the amendment's proposed effective date and
may file such notice of a proposed amendment to a provider agreement only 4 times per
calendar year on January 1st, April 1st, July 1st and October 1st, except that, at any time,
a carrier may file a notice of a proposed amendment in response to a requirement of the
State or Federal Government or due to a change in current procedural terminology codes
used by the American Medical Association. If an amendment that has substantial impact
on the rights and obligations of providers is made to a manual, policy or procedure
document referenced in the provider agreement, such as material changes to fee schedules
or material changes to procedural coding rules specified in the manual, policy or procedure
document, the carrier shall provide 60 days' notice to the provider. If the change is to a
reimbursement policy and the estimated aggregate change to participating provider
reimbursement as a result of the change is more than $500,000 per year, the notice must
include the carrier's good faith estimate of the total annual financial impact of the
amendment on the aggregate amount of reimbursement payments made by the carrier to all
providers within the State with whom the carrier has a provider agreement. After the 60-
day notice period has expired, the amendment to a manual, policy or procedure document
becomes effective and binding on both the carrier and the provider subject to any applicable
termination provisions in the provider agreement, except that the carrier and provider may
mutually agree to waive the 60-day notice requirement. This subsection may not be
construed to limit the ability of a carrier and provider to mutually agree to the proposed
change at any time after the provider has received notice of the proposed amendment. If
the notice required by this subsection is provided by electronic communication, the subject
line of the electronic communication must indicate that notice of an amendment to a
provider agreement or manual, policy or procedure document is included in the
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communication and the notice of the amendment must be provided as an attachment to the
communication, as a separate document. As part of the notice required under this
subsection, a carrier shall provide a copy of the revised provider agreement, manual, policy
or procedure document without changes being noted and a copy of the revised provider
agreement, manual, policy or procedure document with changes being noted by underlining
added language and by striking through deleted language.
Sec. 2. 24-A MRSA §4303, sub-§10, as amended by PL 2007, c. 106, §1, is further
amended to read:
10. Limits on retrospective denials. A Except as provided in paragraphs C and D, a
carrier offering a health plan in this State may not impose on any provider any retrospective
denial of a previously paid claim or any part of that previously paid claim unless: the carrier
has provided the reason for the retrospective denial in writing to the provider and the time
that has elapsed since the date of payment of the previously paid claim does not exceed 12
months.
A. The carrier has provided the reason for the retrospective denial in writing to the
provider; and
B. The time that has elapsed since the date of payment of the previously paid claim
does not exceed 12 months. The retrospective denial of a previously paid claim may
be permitted beyond 12 months from the date of payment only for the following
reasons:
(1) The claim was submitted fraudulently;
(2) The claim payment was incorrect because the provider or the insured was
already paid for the health care services identified in the claim;
(3) The health care services identified in the claim were not delivered by the
provider;
(4) The claim payment was for services covered by Title XVIII, Title XIX or Title
XXI of the Social Security Act;
(5) The claim payment is the subject of adjustment with another insurer,
administrator or payor; or
(6) The claim payment is the subject of legal action.
C. The retrospective denial of a previously paid claim may be permitted from 12
months from the date of payment until no later than 36 months from the date of
payment for the following reasons only:
(1) The claim payment was incorrectly made because the provider or the insured
was already paid in full for the health care services identified in the claim;
(2) The health care services identified in the claim were not delivered by the
provider;
(3) The claim payment is the subject of adjustment with another insurer,
administrator or payor; or
(4) The claim payment is the subject of legal action.
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 D. The retrospective denial of a previously paid claim may be permitted beyond 12
months from the date of payment for the following reasons only:
(1) The claim was submitted fraudulently; or
(2) The claim payment was for services covered by Title XVIII, Title XIX or Title
XXI of the Social Security Act.
For purposes of this subsection, "retrospective denial of a previously paid claim" means
any attempt by a carrier to retroactively collect payments already made to a provider with
respect to a claim by requiring repayment of such payments, reducing other payments
currently owed to the provider, withholding or setting off against future payments or
reducing or affecting the reimbursement rates for future claim payments to the provider in
any other manner. The provider has 6 months from the date of notification under this
subsection to determine whether the insured has other appropriate insurance that was in
effect on the date of service. Notwithstanding the terms of the provider agreement, the
carrier shall allow for the submission of a claim that was previously denied by another
insurer because of the insured's transfer or termination of coverage.
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Statutes affected:
Bill Text LD 1407, HP 903: 24-A.2436, 24-A.4303
Bill Text ACTPUB , Chapter 574: 24-A.4303