Ensures the decision to downcode an insurance claim is recognized as an adverse determination; prohibits health plans from reversing or altering medical necessity determinations made by a utilization review agent or external appeals agent as a result of an audit of claims.
Ensures the decision to downcode an insurance claim is recognized as an adverse determination; prohibits health plans from reversing or altering medical necessity determinations made by a utilization review agent or external appeals agent as a result of an audit of claims.
Relating to utilization review and notice and appeal of certain adverse determinations by utilization review agents.
Prohibits downcoding in health insurance claims.
Prohibits downcoding in health insurance claims.
Provides relative to an internal claims and appeals process and external review procedures for health insurance issuers (EN INCREASE SG RV See Note)
Prohibits downcoding in health insurance claims.
Prohibits downcoding in health insurance claims.
Relating to notice and appeal of an adverse determination by utilization review agents.
Appeals of Agency Determinations