Substitute House Bill No. 6088
Public Act No. 19-155
AN ACT CONCERNING CO NTRACTING HEALTH
ORGANIZATIONS AND DE NTISTS, 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 Section 38a-479 of the general statutes is repealed and the
following is substituted in lieu thereof (Effective January 1, 2020):
(a) As used in this section and section 38a-479b, as amended by this
act:
(1) "Contracting health organization" means a managed care
organization, as defined in section 38a-478, or a preferred provider
network, as defined in section 38a-479aa.
(2) "Provider" means a physician, surgeon, chiropractor, podiatrist,
psychologist, optometrist, dentist, naturopath or advanced practice
registered nurse licensed in this state or a group or organization of
such individuals, who has entered into or renews a participating
provider contract with a contracting health organization to render
services to such organization's enrollees and enrollees' dependents.
(b) Each contracting health organization shall establish and
implement a procedure to provide to each provider: Substitute House Bill No. 6088
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(1) Access via the Internet or other electronic or digital format to the
contracting health organization's fees for (A) the current procedural
terminology (CPT) codes applicable to such provider's specialty or,
upon request, current dental terminology (CDT) codes, (B) the Health
Care Procedure Coding System (HCPCS) codes applicable to such
provider, and (C) such CPT codes, CDT codes and HCPCS codes as
may be requested by such provider for other services such provider
actually bills or intends to bill the contracting health organization,
provided such codes are within t he provider's specialty or
subspecialty; and
(2) Access via the Internet or other electronic or digital format to the
contracting health organization's policies and procedures regarding
(A) payments to providers, (B) providers' duties and requirements
under the participating provider contract, (C) inquiries and appeals
from providers, including contact information for the office or offices
responsible for responding to such inquiries or appeals and a
description of the rights of a provider, enrollee and enrollee's
dependents with respect to an appeal.
(c) The provisions of subdivision (1) of subsection (b) of this section
shall not apply to any provider whose services are reimbursed in a
manner that does not utilize current procedural terminology (CPT) or
current dental terminology (CDT) codes.
(d) The fee information received by a provider pursuant to
subdivision (1) of subsection (b) of this section is proprietary and shall
be confidential, and the procedure adopted pursuant to this section
may contain penalties for the unauthorized distribution of fee
information, which may include termination of the participating
provider contract.
Sec. 2. Section 38a-479b of the general statutes is repealed and the
following is substituted in lieu thereof (Effective January 1, 2020): Substitute House Bill No. 6088
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(a) No contracting health organization shall make material changes
to a provider's fee schedule except as follows:
(1) At one time annually, provided providers are given at least
ninety days' advance notice by mail, electronic mail or facsimile by
such organization of any such changes. Upon receipt of such notice, a
provider may terminate the participating provider contract with at
least sixty days' advance written notice to the contracting health
organization;
(2) At any time for the following, provided providers are given at
least thirty days' advance notice by mail, electronic mail or facsimile by
such organization of any such changes:
(A) To comply with requirements of federal or state law, regulation
or policy. If such federal or state law, regulation or policy takes effect
in less than thirty days, the organization shall give providers as much
notice as possible;
(B) To comply with changes to the medical data code sets set forth
in 45 CFR 162.1002, as amended from time to time;
(C) To comply with changes to national best practice protocols made
by the National Quality Forum or other national accrediting or
standard-setting organization based on peer-reviewed medical
literature generally recognized by the relevant medical community or
the results of clinical trials generally recognized and accepted by the
relevant medical community;
(D) To be consistent with changes made in Medicare pertaining to
billing or medical management practices, provided any such changes
are applied to relevant participating provider contracts where such
changes pertain to the same specialty or payment methodology;
(E) If a drug, treatment, procedure or device is identified as no Substitute House Bill No. 6088
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longer safe and effective by the federal Food and Drug Administration
or by peer-reviewed medical literature generally recognized by the
relevant medical community;
(F) To address payment or reimbursement for a new drug,
treatment, procedure or device that becomes available and is
determined to be safe and effective by the federal Food and Drug
Administration or by peer-reviewed medical literature generally
recognized by the relevant medical community; or
(G) As mutually agreed to by the contracting health organization
and the provider. If the contracting health organization and the
provider do not mutually agree, the provider's current fee schedule
shall remain in force until the annual change permitted pursuant to
subdivision (1) of this subsection.
(b) Notwithstanding subsection (a) of this section, a contracting
health organization may introduce a new insurance product to a
provider at any time, provided such provider is given at least sixty
days' advance notice by mail, electronic mail or facsimile by such
organization if the introduction of such insurance product will make
material changes to the provider's administrative requirements under
the participating provider contract or to the provider's fee schedule.
The provider may decline to participate in such new product by
providing notice to the contracting health organization as set forth in
the advance notice, which shall include a period of not less than thirty
days for a provider to decline, or in accordance with the time frames
under the applicable terms of such provider's participating provider
contract.
(c) (1) No contracting health organization shall cancel, deny or
demand the return of full or partial payment for an authorized covered
service due to administrative or eligibility error, more than eighteen
months after the date of the receipt of a clean claim, except if: Substitute House Bill No. 6088
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(A) Such organization has a documented basis to believe that such
claim was submitted fraudulently by such provider;
(B) The provider did not bill appropriately for such claim based on
the documentation or evidence of what medical service was actually
provided;
(C) Such organization has paid the provider for such claim more
than once;
(D) Such organization paid a claim that should have been or was
paid by a federal or state program; or
(E) The provider received payment for such claim from a different
insurer, payor or administrator through coordination of benefits or
subrogation, or due to coverage under an automobile insurance or
workers' compensation policy. Such provider shall have one year after
the date of the cancellation, denial or return of full or partial payment
to resubmit an adjusted secondary payor claim with such organization
on a secondary payor basis, regardless of such organization's timely
filing requirements.
(2) (A) Such organization shall give at least thirty days' advance
notice to a provider by mail, electronic mail or facsimile of the
organization's cancellation, denial or demand for the return of full or
partial payment pursuant to subdivision (1) of this subsection.
(B) If such organization demands the return of full or partial
payment from a provider, the notice required under subparagraph (A)
of this subdivision shall disclose to the provider (i) the amount that is
demanded to be returned, (ii) the claim that is the subject of such
demand, and (iii) the basis on which such return is being demanded.
(C) Not later than thirty days after the receipt of the notice required
under subparagraph (A) of this subdivision, a provider may appeal Substitute House Bill No. 6088
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such cancellation, denial or demand in accordance with the procedures
provided by such organization. Any demand for the return of full or
partial payment shall be stayed during the pendency of such appeal.
(D) If there is no appeal or an appeal is denied, such provider may
resubmit an adjusted claim, if applicable, to such organization, not
later than thirty days after the receipt of the notice required under
subparagraph (A) of this subdivision or the denial of the appeal,
whichever is applicable, except that if a return of payment was
demanded pursuant to subparagraph (C) of subdivision (1) of this
subsection, such claim shall not be resubmitted.
(E) A provider shall have one year after the date of the written
notice set forth in subparagraph (A) of this subdivision to identify any
other appropriate insurance coverage applicable on the date of service
and to file a claim with such insurer, health care center or other issuing
entity, regardless of such insurer's, health care center's or other issuing
entity's timely filing requirements.
(d) Except as provided in subsection (e) of this section, no
contracting health organization shall include in any participating
provider contract [, contract with a dentist] or contract with a hospital
licensed under chapter 368v, that is entered into, renewed or amended
on or after October 1, 2011, or contract offered to a provider [, dentist]
or hospital on or after October 1, 2011, any clause, covenant or
agreement that:
(1) Requires the provider [, dentist] or hospital to:
(A) Disclose to the contracting health organization the provider's [,
dentist's] or hospital's payment or reimbursement rates from any other
contracting health organization the provider [, dentist] or hospital has
contracted, or may contract, with;
(B) Provide services or procedures to the contracting health Substitute House Bill No. 6088
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organization at a payment or reimbursement rate equal to or lower
than the lowest of such rates the provider [, dentist] or hospital has
contracted, or may contract, with any other contracting health
organization;
(C) Certify to the contracting health organization that the provider [,
dentist] or hospital has not contracted with any other contracting
health organization to provide services or procedures at a payment or
reimbursement rate lower than the rates contracted for with the
contracting health organization;
(2) Prohibits or limits the provider [, dentist] or hospital from
contracting with any other contracting health organization to provide
services or procedures at a payment or reimbursement rate lower than
the rates contracted for with the contracting health organization; or
(3) Allows the contracting health organization to terminate or
renegotiate a contract with the provider [, dentist] or hospital prior to
renewal if the provider [, dentist] or hospital contracts with any other
contracting health organization to provide services or procedures at a
lower payment or reimbursement rate than the rates contracted for
with the contracting health organization.
(e) (1) If a contract described in subsection (d) of this section is in
effect prior to October 1, 2011, and includes a clause, covenant or
agreement set forth under subdivisions (1) to (3), inclusive, of said
subsection (d), such clause, covenant or agreement shall be void and
unenforceable on the date such contract is next renewed or on January
1, 2014, whichever is earlier. Such invalidity shall not affect other
provisions of such contract.
(2) Nothing in subdivision (1) of this subsection shall be construed
to affect the rights of a contracting health organization to enforce such
clause, covenant or agreement prior to the invalidation of such clause, Substitute House Bill No. 6088
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covenant or agreement.
Sec. 3. Section 38a-472c of the general statutes is repealed and the
following is substituted in lieu thereof (Effective January 1, 2020):
(a) For any policy delivered, issued for delivery, renewed, amended
or continued in this state that provides coverage for inpatient or
outpatient dental services only, the person who issues the policy shall
provide the insured or a licensed dentist acting on behalf of the
insured, upon request, an estimate of reimbursement under the policy
with respect to specific dental procedure codes ordered or
recommended for the insured by a licensed dentist, except that the
actual reimbursement may be adjusted based on factors such as the
insured's eligibility, plan design, utilization of benefits and the actual
claim submitted.
(b) No person that issues a policy described in subsection (a) of this
section that uses a provider network for such policy shall materially
adjust the fee schedule for in-network providers more than once
annually.
(c) Each person that makes a material adjustment described in
subsection (b) of this section shall issue a notice to each in-network
provider at least ninety days before the effective date of such
adjustment. Each such notice shall be sent by mail, electronic mail or
facsimile, and disclose:
(1) The percentage effect that such adjustment will have on such
provider's fees; or
(2) A measure, other than the measure described in subdivision (1)
of this subsection, that will enable such provider to understand how
such adjustment will affect such provider's fees for the twenty covered
procedures that such provider most frequently performed, and for
which such provider sought reimbursement, during the twelve months Substitute House Bill No. 6088
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immediately preceding the date of such notice.