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General Assembly Substitute Bill No. 6088
January Session, 2019
AN ACT CONCERNING CO NTRACTING HEALTH ORG ANIZATIONS
AND DENTISTS, DENTAL PLANS AND PROCEDURES.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Section 38a-479 of the general statutes is repealed and the 1
following is substituted in lieu thereof (Effective January 1, 2020): 2
(a) As used in this section and section 38a-479b, as amended by this 3
act: 4
(1) "Contracting health organization" means a managed care 5
organization, as defined in section 38a-478, or a preferred provider 6
network, as defined in section 38a-479aa. 7
(2) "Provider" means a physician, surgeon, chiropractor, podiatrist, 8
psychologist, optometrist, dentist, naturopath or advanced practice 9
registered nurse licensed in this state or a group or organization of 10
such individuals, who has entered into or renews a participating 11
provider contract with a contracting health organization to render 12
services to such organization's enrollees and enrollees' dependents. 13
(b) Each contracting health organization shall establish and 14
implement a procedure to provide to each provider: 15
(1) Access via the Internet or other electronic or digital format to the 16
contracting health organization's fees for (A) the current procedural 17
terminology (CPT) codes or current dental terminology (CDT) codes 18 Substitute Bill No. 6088
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applicable to such provider's specialty, (B) the Health Care Procedure 19
Coding System (HCPCS) codes applicable to such provider, and (C) 20
such CPT codes, CDT codes and HCPCS codes as may be requested by 21
such provider for other services such provider actually bills or intends 22
to bill the contracting health organization, provided such codes are 23
within the provider's specialty or subspecialty; and 24
(2) Access via the Internet or other electronic or digital format to the 25
contracting health organization's policies and procedures regarding 26
(A) payments to providers, (B) providers' duties and requirements 27
under the participating provider contract, (C) inquiries and appeals 28
from providers, including contact information for the office or offices 29
responsible for responding to such inquiries or appeals and a 30
description of the rights of a provider, enrollee and enrollee's 31
dependents with respect to an appeal. 32
(c) The provisions of subdivision (1) of subsection (b) of this section 33
shall not apply to any provider whose services are reimbursed in a 34
manner that does not utilize current procedural terminology (CPT) or 35
current dental terminology (CDT) codes. 36
(d) The fee information received by a provider pursuant to 37
subdivision (1) of subsection (b) of this section is proprietary and shall 38
be confidential, and the procedure adopted pursuant to this section 39
may contain penalties for the unauthorized distribution of fee 40
information, which may include termination of the participating 41
provider contract. 42
Sec. 2. Section 38a-479b of the general statutes is repealed and the 43
following is substituted in lieu thereof (Effective January 1, 2020): 44
(a) No contracting health organization shall make material changes 45
to a provider's fee schedule except as follows: 46
(1) At one time annually, provided providers are given at least 47
ninety days' advance notice by mail, electronic mail or facsimile by 48
such organization of any such changes. With respect to a dental plan, 49 Substitute Bill No. 6088
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such notice shall include the maximum allowable charge for each 50
dental procedure code. Upon receipt of such notice, a provider may 51
terminate the participating provider contract with at least sixty days' 52
advance written notice to the contracting health organization; 53
(2) At any time for the following, provided providers are given at 54
least thirty days' advance notice by mail, electronic mail or facsimile by 55
such organization of any such changes: 56
(A) To comply with requirements of federal or state law, regulation 57
or policy. If such federal or state law, regulation or policy takes effect 58
in less than thirty days, the organization shall give providers as much 59
notice as possible; 60
(B) To comply with changes to the medical data code sets set forth 61
in 45 CFR 162.1002, as amended from time to time; 62
(C) To comply with changes to national best practice protocols made 63
by the National Quality Forum or other national accrediting or 64
standard-setting organization based on peer-reviewed medical 65
literature generally recognized by the relevant medical community or 66
the results of clinical trials generally recognized and accepted by the 67
relevant medical community; 68
(D) To be consistent with changes made in Medicare pertaining to 69
billing or medical management practices, provided any such changes 70
are applied to relevant participating provider contracts where such 71
changes pertain to the same specialty or payment methodology; 72
(E) If a drug, treatment, procedure or device is identified as no 73
longer safe and effective by the federal Food and Drug Administration 74
or by peer-reviewed medical literature generally recognized by the 75
relevant medical community; 76
(F) To address payment or reimbursement for a new drug, 77
treatment, procedure or device that becomes available and is 78
determined to be safe and effective by the federal Food and Drug 79 Substitute Bill No. 6088
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Administration or by peer-reviewed medical literature generally 80
recognized by the relevant medical community; or 81
(G) As mutually agreed to by the contracting health organization 82
and the provider. If the contracting health organization and the 83
provider do not mutually agree, the provider's current fee schedule 84
shall remain in force until the annual change permitted pursuant to 85
subdivision (1) of this subsection. 86
(b) Notwithstanding subsection (a) of this section, a contracting 87
health organization may introduce a new insurance product to a 88
provider at any time, provided such provider is given at least sixty 89
days' advance notice by mail, electronic mail or facsimile by such 90
organization if the introduction of such insurance product will make 91
material changes to the provider's administrative requirements under 92
the participating provider contract or to the provider's fee schedule. 93
The provider may decline to participate in such new product by 94
providing notice to the contracting health organization as set forth in 95
the advance notice, which shall include a period of not less than thirty 96
days for a provider to decline, or in accordance with the time frames 97
under the applicable terms of such provider's participating provider 98
contract. 99
(c) (1) No contracting health organization shall cancel, deny or 100
demand the return of full or partial payment for an authorized covered 101
service due to administrative or eligibility error, more than eighteen 102
months after the date of the receipt of a clean claim, except if: 103
(A) Such organization has a documented basis to believe that such 104
claim was submitted fraudulently by such provider; 105
(B) The provider did not bill appropriately for such claim based on 106
the documentation or evidence of what medical service was actually 107
provided; 108
(C) Such organization has paid the provider for such claim more 109
than once; 110 Substitute Bill No. 6088
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(D) Such organization paid a claim that should have been or was 111
paid by a federal or state program; or 112
(E) The provider received payment for such claim from a different 113
insurer, payor or administrator through coordination of benefits or 114
subrogation, or due to coverage under an automobile insurance or 115
workers' compensation policy. Such provider shall have one year after 116
the date of the cancellation, denial or return of full or partial payment 117
to resubmit an adjusted secondary payor claim with such organization 118
on a secondary payor basis, regardless of such organization's timely 119
filing requirements. 120
(2) (A) Such organization shall give at least thirty days' advance 121
notice to a provider by mail, electronic mail or facsimile of the 122
organization's cancellation, denial or demand for the return of full or 123
partial payment pursuant to subdivision (1) of this subsection. 124
(B) If such organization demands the return of full or partial 125
payment from a provider, the notice required under subparagraph (A) 126
of this subdivision shall disclose to the provider (i) the amount that is 127
demanded to be returned, (ii) the claim that is the subject of such 128
demand, and (iii) the basis on which such return is being demanded. 129
(C) Not later than thirty days after the receipt of the notice required 130
under subparagraph (A) of this subdivision, a provider may appeal 131
such cancellation, denial or demand in accordance with the procedures 132
provided by such organization. Any demand for the return of full or 133
partial payment shall be stayed during the pendency of such appeal. 134
(D) If there is no appeal or an appeal is denied, such provider may 135
resubmit an adjusted claim, if applicable, to such organization, not 136
later than thirty days after the receipt of the notice required under 137
subparagraph (A) of this subdivision or the denial of the appeal, 138
whichever is applicable, except that if a return of payment was 139
demanded pursuant to subparagraph (C) of subdivision (1) of this 140
subsection, such claim shall not be resubmitted. 141 Substitute Bill No. 6088
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(E) A provider shall have one year after the date of the written 142
notice set forth in subparagraph (A) of this subdivision to identify any 143
other appropriate insurance coverage applicable on the date of service 144
and to file a claim with such insurer, health care center or other issuing 145
entity, regardless of such insurer's, health care center's or other issuing 146
entity's timely filing requirements. 147
(d) Except as provided in subsection (e) of this section, no 148
contracting health organization shall include in any participating 149
provider contract [, contract with a dentist] or contract with a hospital 150
licensed under chapter 368v, that is entered into, renewed or amended 151
on or after October 1, 2011, or contract offered to a provider [, dentist] 152
or hospital on or after October 1, 2011, any clause, covenant or 153
agreement that: 154
(1) Requires the provider [, dentist] or hospital to: 155
(A) Disclose to the contracting health organization the provider's [, 156
dentist's] or hospital's payment or reimbursement rates from any other 157
contracting health organization the provider [, dentist] or hospital has 158
contracted, or may contract, with; 159
(B) Provide services or procedures to the contracting health 160
organization at a payment or reimbursement rate equal to or lower 161
than the lowest of such rates the provider [, dentist] or hospital has 162
contracted, or may contract, with any other contracting health 163
organization; 164
(C) Certify to the contracting health organization that the provider [, 165
dentist] or hospital has not contracted with any other contracting 166
health organization to provide services or procedures at a payment or 167
reimbursement rate lower than the rates contracted for with the 168
contracting health organization; 169
(2) Prohibits or limits the provider [, dentist] or hospital from 170
contracting with any other contracting health organization to provide 171
services or procedures at a payment or reimbursement rate lower than 172 Substitute Bill No. 6088
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the rates contracted for with the contracting health organization; or 173
(3) Allows the contracting health organization to terminate or 174
renegotiate a contract with the provider [, dentist] or hospital prior to 175
renewal if the provider [, dentist] or hospital contracts with any other 176
contracting health organization to provide services or procedures at a 177
lower payment or reimbursement rate than the rates contracted for 178
with the contracting health organization. 179
(e) (1) If a contract described in subsection (d) of this section is in 180
effect prior to October 1, 2011, and includes a clause, covenant or 181
agreement set forth under subdivisions (1) to (3), inclusive, of said 182
subsection (d), such clause, covenant or agreement shall be void and 183
unenforceable on the date such contract is next renewed or on January 184
1, 2014, whichever is earlier. Such invalidity shall not affect other 185
provisions of such contract. 186
(2) Nothing in subdivision (1) of this subsection shall be construed 187
to affect the rights of a contracting health organization to enforce such 188
clause, covenant or agreement prior to the invalidation of such clause, 189
covenant or agreement. 190
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2020 38a-479
Sec. 2 January 1, 2020 38a-479b
Statement of Legislative Commissioners:
In Section 2(d), ", contract with a dentist", ", dentist" and ", dentist's"
were bracketed to conform with the changes being made in Section
1(a)(2).
INS Joint Favorable Subst. -LCO