As used in this subchapter: (1) “Covered person” means a person on whose behalf a health care insurer offering health insurance coverage is obligated to pay benefits or provide services; (2) “Healthcare insurer” means an entity subject to the insurance laws of this state or the jurisdiction of the Insurance Commissioner that contracts or offers […]
(a) (1) Except in cases of fraud committed by a healthcare provider, a healthcare insurer may exercise recoupment from a healthcare provider only during the eighteen-month period after the date that the healthcare insurer paid the claim submitted by the healthcare provider. (2) A healthcare provider may submit a corrected claim for up to six […]
(a) If a health care insurer determines that payment was made for services not covered under the covered person’s health insurance coverage, the health care insurer shall give written notice to the health care provider of its intent to exercise recoupment and may: (1) Request a refund from the health care provider; or (2) Make […]
If a health care insurer exercises recoupment, then the health care insurer shall provide the health care provider written documentation that specifies the: (1) Amount of the recoupment; (2) Covered person’s name to whom the recoupment applies; (3) Patient identification number; (4) Date or dates of service; (5) Service or services on which the recoupment […]
The failure to comply with any provision of this subchapter shall be deemed an unfair trade practice under the Trade Practices Act, § 23-66-201 et seq., and may be punished by the fines and penalties established under §§ 23-60-108, 23-66-210, and 23-66-215.
The Insurance Commissioner shall adopt rules by January 1, 2006, to ensure compliance with this subchapter.
The provisions of this subchapter shall not be waived, voided, or nullified by contract.
The provisions of this subchapter that allow for audit recoupment from healthcare providers do not apply to a service that was authorized under § 23-99-1109, § 23-99-1113, or § 23-99-1116, except as provided for in § 23-99-1109(b).
