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An Act To Further Limit Retrospective Denials of Previously Paid Health Insurance Claims
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §4303, sub-§10, ¶B,  as enacted by PL 2003, c. 218, §9, is amended to read:
 
B.  The time that has elapsed since the date of payment of the previously paid claim does not exceed 1812 months. The retrospective denial of a previously paid claim may be permitted beyond 1812 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.
 
SUMMARY
The bill shortens the time frame from 18 months to 12 months in which a health insurance carrier may deny retrospectively a health insurance claim submitted by a health care provider and processed and paid in accordance with the standards in effect at the time of submission.