HOUSE DOCKET, NO. 1539        FILED ON: 1/17/2013

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 983

The Commonwealth of Massachusetts

_________________

PRESENTED BY:

John W. Scibak

_________________

To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:

The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:

An Act to limit retroactive denials of dental insurance claims.

_______________

PETITION OF:

HOUSE DOCKET, NO. 1539        FILED ON: 1/17/2013

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 983

The Commonwealth of Massachusetts

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In the Year Two Thousand Thirteen

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An Act to limit retroactive denials of dental insurance claims.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
 

SECTION 1.Section 108B of Chapter 175 of the General Laws, as appearing in the 2008 Official Edition, is hereby amended by at the end thereof the following new paragraph:-

“In this paragraph “retroactive denial of a previously paid claim” means any attempt by an insurer to retroactively collect payments already made to a registered dentist with respect to a claim by requiring re-payment of such payments, reducing other payments currently owed to the dentist, withholding or setting off against future payments, or reducing or affecting the future claim payments to the dentist in any other manner.  The insurer shall not impose on any registered dentist any retroactive denial of a previously paid claim or any part thereof unless:

(a) The insurer has provided the reason for the retroactive denial in writing to the dentist; and

(b) The time which has elapsed since the date of payment of the claim does not exceed 12 months.  The retroactive 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 dentist or the insured was already paid for the dental care services identified in the claim;

(3) The dental care services identified in the claim were not delivered by the dentist;

(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.

An insurer shall notify a dentist at least 15 days in advance of the imposition of any retroactive denials of previously paid claims.  The dentist shall have 6 months from the date of notification under this paragraph to determine whether the insured has other appropriate insurance, which was in effect on the date of service.  Notwithstanding the contractual terms between the corporation and dentist, the corporation shall allow for the submission of a claim that was previously denied by another insurer due to the insured’s transfer or termination of coverage.”

SECTION 2.Section 7 of chapter 176B of the General Laws, as appearing in the 2008 Official Edition, is hereby amended by at the end thereof the following new paragraph:-

“In this paragraph “retroactive denial of a previously paid claim” means any attempt by a corporation to retroactively collect payments already made to a registered dentist with respect to a claim by requiring re-payment of such payments, reducing other payments currently owed to the dentist, withholding or setting off against future payments, or reducing or affecting the future claim payments to the dentist in any other manner.  The corporation shall not impose on any registered dentist any retroactive denial of a previously paid claim or any part thereof unless:

(a) The corporation has provided the reason for the retroactive denial in writing to the dentist; and

(b) The time which has elapsed since the date of payment of the claim does not exceed 12 months.  The retroactive 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 dentist or the insured was already paid for the dental care services identified in the claim;

(3) The dental care services identified in the claim were not delivered by the dentist;

(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.

A corporation shall notify a dentist at least 15 days in advance of the imposition of any retroactive denials of previously paid claims.  The dentist shall have 6 months from the date of notification under this paragraph to determine whether the insured has other appropriate insurance, which was in effect on the date of service.  Notwithstanding the contractual terms between the corporation and dentist, the corporation shall allow for the submission of a claim that was previously denied by another insurer due to the insured’s transfer or termination of coverage.”

SECTION 3.Section 7 of chapter 176E of the General Laws, as appearing in the 2008 Official Edition is hereby amended by at the end thereof the following new paragraph:-

“In this paragraph “retroactive denial of a previously paid claim” means any attempt by the corporation to retroactively collect payments already made to a registered dentist with respect to a claim by requiring re-payment of such payments, reducing other payments currently owed to the dentist, withholding or setting off against future payments, or reducing or affecting the future claim payments to the dentist in any other manner.  The corporation shall not impose on any registered dentist any retroactive denial of a previously paid claim or any part thereof unless:

(a) The corporation has provided the reason for the retroactive denial in writing to the dentist; and

(b) The time which has elapsed since the date of payment of the claim does not exceed 12 months.  The retroactive 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 dentist or the insured was already paid for the dental care services identified in the claim;

(3) The dental care services identified in the claim were not delivered by the dentist;

(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.

The corporation shall notify a dentist at least 15 days in advance of the imposition of any retroactive denials of previously paid claims.  The dentist shall have 6 months from the date of notification under this paragraph to determine whether the insured has other appropriate insurance, which was in effect on the date of service.  Notwithstanding the contractual terms between the corporation and dentist, the corporation shall allow for the submission of a claim that was previously denied by another insurer due to the insured’s transfer or termination of coverage.”

SECTION 4.Section 21 of chapter 176G of the General Laws, as appearing in the 2008 Official Edition, is hereby amended by inserting after sub-section (d) the following sub-section:-

“(e) In this subsection “retroactive denial of a previously paid claim” means any attempt by a health maintenance organization to retroactively collect payments already made to a registered dentist with respect to a claim by requiring re-payment of such payments, reducing other payments currently owed to the dentist, withholding or setting off against future payments, or reducing or affecting the future claim payments to the dentist in any other manner.  The health maintenance organization shall not impose on any registered dentist any retroactive denial of a previously paid claim or any part thereof unless:

(a) The health maintenance organization has provided the reason for the retroactive denial in writing to the dentist; and

(b) The time which has elapsed since the date of payment of the claim does not exceed 12 months.  The retroactive 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 dentist or the insured was already paid for the dental care services identified in the claim;

(3) The dental care services identified in the claim were not delivered by the dentist;

(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.

A health maintenance organization shall notify a dentist at least 15 days in advance of the imposition of any retroactive denials of previously paid claims.  The dentist shall have 6 months from the date of notification under this paragraph to determine whether the insured has other appropriate insurance, which was in effect on the date of service.  Notwithstanding the contractual terms between the health maintenance organization and dentist, the corporation shall allow for the submission of a claim that was previously denied by another insurer due to the insured’s transfer or termination of coverage.”

SECTION 5.Section 2 of chapter 176I of the General Laws, as appearing in the 2008 Official Edition, is hereby amended by at the end thereof the following new paragraph:-

“In this paragraph “retroactive denial of a previously paid claim” means any attempt by an organization to retroactively collect payments already made to a registered dentist with respect to a claim by requiring re-payment of such payments, reducing other payments currently owed to the dentist, withholding or setting off against future payments, or reducing or affecting the future claim payments to the dentist in any other manner.  The organization shall not impose on any registered dentist any retroactive denial of a previously paid claim or any part thereof unless:

(a) The organization has provided the reason for the retroactive denial in writing to the dentist; and

(b) The time which has elapsed since the date of payment of the claim does not exceed 12 months.  The retroactive 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 dentist or the insured was already paid for the dental care services identified in the claim;

(3) The dental care services identified in the claim were not delivered by the dentist;

(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.

An organization shall notify a dentist at least 15 days in advance of the imposition of any retroactive denials of previously paid claims.  The dentist shall have 6 months from the date of notification under this paragraph to determine whether the insured has other appropriate insurance, which was in effect on the date of service.  Notwithstanding the contractual terms between the corporation and dentist, the corporation shall allow for the submission of a claim that was previously denied by another insurer due to the insured’s transfer or termination of coverage.”