Connecticut HB 5377: AN ACT CONCERNING RETURN OF HEALTH CARE PROVIDER PAYMENTS.

Bill Text

Substitute House Bill No. 5377 
 
Public Act No. 26-56 
 
 
AN  ACT  CONCERNING  RETURN  OF  HEALTH  CARE  PROVIDER 
PAYMENTS. 
Be  it  enacted  by  the  Senate  and  House  of  Representatives  in  General 
Assembly convened: 
 
Section 1. Subsection (c) of section 38a-479b of the general statutes is 
repealed and the following is substituted in lieu thereof (Effective January 
1, 2027): 
(c) (1) No  contracting  health  organization  shall  cancel,  deny  or 
demand the return of full or partial payment for an authorized covered 
service  due  to  administrative  or  eligibility  error,  more  than [eighteen] 
twelve months after the date of the receipt of a clean claim, except if: 
(A) Such  organization  has  a  documented  basis  to  believe  that  such 
claim was submitted fraudulently by such provider; 
(B) The provider did not bill appropriately for such claim based on 
the  documentation  or  evidence  of  what  medical  service  was  actually 
provided; 
(C) Such organization has paid the provider for such claim more than 
once; 
(D) Such organization paid a claim that should have been or was paid 

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by a federal or state program; or 
(E) The  provider  received  payment  for  such  claim  from  a  different 
insurer,  payor  or  administrator  through  coordination  of  benefits  or 
subrogation,  or  due  to  coverage  under  an  automobile  insurance  or 
workers' compensation policy. Such provider shall have one year after 
the date of the cancellation, denial or return of full or partial payment to 
resubmit an adjusted secondary payor claim with such organization on 
a secondary payor basis, regardless of such organization's timely filing 
requirements. 
(2) (A) Such  organization  shall  give  at  least  thirty  days'  advance 
notice to a provider by [mail, electronic mail or facsimile] certified mail, 
return receipt requested, electronic mail to such electronic mail address 
designated by such provider or facsimile, or through a secure electronic 
provider portal or electronic clearinghouse used for claims or remittance 
communications, of  the  organization's  cancellation,  denial  or  demand 
for the return of full or partial payment pursuant to subdivision (1) of 
this subsection. 
(B) If such organization demands the return of full or partial payment 
from  a  provider,  the  notice  required  under  subparagraph  (A)  of  this 
subdivision   shall   disclose   to   the   provider   (i)   the   amount   that   is 
demanded  to  be  returned,  (ii)  the  claim  that  is  the  subject  of  such 
demand, and (iii) the basis on which such return is being demanded. 
(C) Not later than thirty days after the receipt of the notice required 
under subparagraph (A) of this subdivision, a provider may appeal such 
cancellation,  denial  or  demand  in  accordance  with  the  procedures 
provided  by  such  organization,  which  shall  include,  but  need  not  be 
limited to, an electronic appeal process. If any such organization fails to 
notify the provider of such organization's determination of such appeal 
not later than thirty business days after receipt of such appeal from such 
provider, such appeal shall be construed in favor of such provider. Any 

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demand for the return of full or partial payment shall be stayed during 
the pendency of such appeal. 
(D) If  there  is  no  appeal  or  an  appeal  is  denied,  such  provider  may 
resubmit an adjusted claim, if applicable, to such organization, not later 
than   thirty   days   after   the   receipt   of   the   notice   required   under 
subparagraph  (A)  of  this  subdivision  or  the  denial  of the  appeal, 
whichever   is   applicable,   except   that   if   a   return  of   payment  was 
demanded  pursuant  to  subparagraph  (C)  of  subdivision  (1)  of  this 
subsection, such claim shall not be resubmitted. 
(E) A provider shall have one year after the date of the written notice 
set forth in subparagraph (A) of this subdivision to identify any other 
appropriate insurance coverage applicable on the date of service and to 
file a claim with such insurer, health care center or other issuing entity, 
regardless of such insurer's, health care center's or other issuing entity's 
timely filing requirements. 
Sec.  2.  (NEW)  (Effective  January  1,  2027)  (a)  For  the  purposes  of  this 
section,  "health  care  provider"  has  the  same  meaning  as  provided  in 
section 38a-477aa of the general statutes. 
(b)  (1)  No  insurer,  health  care  center,  fraternal  benefit  society, 
hospital service corporation, medical service corporation or other entity 
delivering, issuing for  delivery, renewing, amending or continuing an 
individual  or  group  health  insurance  policy  in  this  state  on  or  after 
January 1, 2027, providing coverage of the type specified in subdivisions 
(1), (2), (4), (11)