New York A03707 ensures downcoding an insurance claim is recognized as an adverse determination and prohibits health plans from altering medical.

New York A03707 amends the insurance and public health laws to ensure that downcoding an insurance claim is recognized as an adverse determination. It 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. This protection applies unless there is a reasonable suspicion of fraud or abuse. The bill also mandates that insurers provide specific reasons for initial adjustments and allows hospitals to submit supporting medical records within 30 days of payment receipt.

New York A03707 ensures downcoding an insurance claim is recognized as an adverse determination and prohibits health plans from altering medical.

New York A03707 amends the insurance and public health laws to ensure that downcoding an insurance claim is recognized as an adverse determination. It 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. This protection applies unless there is a reasonable suspicion of fraud or abuse. The bill also mandates that insurers provide specific reasons for initial adjustments and allows hospitals to submit supporting medical records within 30 days of payment receipt.