California AB2431 prohibits downcoding of medical claims without clear justification and mandates transparency and appeal rights for providers.

California AB2431 aims to prevent insurers from downcoding medical claims without proper justification. Downcoding refers to the unilateral alteration of service or procedure codes by a payer, resulting in lower payment. The bill mandates that downcoding decisions must be made by licensed professionals and cannot be based solely on information reported on the claim form. If a claim is downcoded, insurers must provide a clear explanation, including the specific reasons, the original and revised service codes, and payment amounts.

California AB2431 prohibits downcoding of medical claims without clear justification and mandates transparency and appeal rights for providers.

California AB2431 aims to prevent insurers from downcoding medical claims without proper justification. Downcoding refers to the unilateral alteration of service or procedure codes by a payer, resulting in lower payment. The bill mandates that downcoding decisions must be made by licensed professionals and cannot be based solely on information reported on the claim form. If a claim is downcoded, insurers must provide a clear explanation, including the specific reasons, the original and revised service codes, and payment amounts.