Section 55 Retroactive Claims Denials for Behavioral Health Services 5

Section 108 of said chapter 175, as so appearing, is hereby amended by adding the following subdivision:-

14. (a) For the purposes of this section, "provider" shall mean (i) a mental health clinic or substance use disorder treatment program licensed by the department of public health under chapters 17, 111, 111B or 111E; or (ii) a behavioral, substance use disorder or mental health professional who is licensed under chapter 112 and accredited or certified to provide behavioral health services and who has provided such services under an express or implied contract or with the expectation of receiving payment, other than co-payment, deductible or co-insurance, directly or indirectly from an insurer or other entity.

(b) No insurer or other entity shall impose a retroactive claims denial for behavioral health services on a provider unless: (i) less than 12 months have elapsed from the time of submission of the claim by the provider to the insurer or other entity responsible for payment; (ii) the insurer or other entity has furnished the provider with a written explanation of the reason for the retroactive claims denial and, where applicable, a description of additional documentation or other any corrective action required for payment of the claim; and (iii) where applicable, the insurer or other entity responsible for payment allows the provider 30 days to submit additional documentation or to take other corrective action required for payment of the claim.

(c) Notwithstanding subsection (b), a retroactive claims denial may be allowed after 12 months if: (i) the claim was submitted fraudulently; (ii) the claim, or behavioral health services for which the claim was submitted, is the subject of legal action; (iii) the claim payment was incorrect because the provider was paid or the insured has already paid for the behavioral health services identified in the claim; or (iv) the behavioral health services identified in the claim were not delivered by the provider.

(d) If a retroactive claims denial is imposed because the claim payment is subject to adjustment due to expected payment from a payer other than the insurer or an entity with which the insurer contracts to provide or manage health insurance benefits, including mental health and substance use disorder services, the insurer or other entity shall notify the provider not less than 15 days before imposing the retroactive claims denial. The provider shall have 12 months from the date of denial to determine whether the claim is subject to payment by a secondary insurer; provided, however, that if the claim is denied by the secondary insurer due to the insured's transfer or termination of coverage, the insurer shall allow for resubmission of the claim.