No. SB 1198
Filed under Insurance.
Health Insurance Claims; Expanding the scope of the statewide provider and health plan claim dispute resolution program to include resolution of denied prior authorization requests; providing that participation in the program is mandatory and prohibiting providers and health plans from opting out of the claim dispute resolution process; prohibiting contracts between certain physicians and health insurers and health maintenance organizations, respectively, from specifying credit card payments to physicians as the only acceptable method for payments; authorizing use of electronic funds transfers by health insurers and health maintenance organizations, respectively, for payments to physicians under certain circumstances, etc.
Plain English Summary
AI-GENERATEDThe statewide claim dispute program at the state health agency becomes mandatory, and providers and health plans can no longer opt out. Disputes over denied, delayed, or overly restrictive prior authorizations are now explicitly covered by the same process.
That same mandatory process now also governs Medicaid managed care provider disputes, which previously could use it only if the parties chose to, and out-of-network emergency-service reimbursement disputes, which the law had called voluntary until now.
Health insurers and HMOs can no longer force dentists or physicians into credit-card-only payment, and they cannot deny a claim for a procedure that was already pre-authorized, except in a short list of situations.
When a health plan loses a prior-authorization dispute, it must now pay the provider's reasonable costs of bringing the claim. The new physician protections apply only to contracts renewed on or after January 1, 2027.
AIProviders and health plans can no longer opt out of the statewide claim dispute process, and its scope now expressly reaches prior authorization requests that are denied, left unanswered past the deadline, or approved with conditions too restrictive to actually deliver the service.
AIWhen a claim dispute over a denied prior authorization goes against the health plan, the plan must now reimburse the provider's reasonable costs of bringing the claim, including filing fees and administrative costs the agency assessed.
AIContracts between health insurers or HMOs and a physician licensed under chapter 458 or 459 -- not just dentists -- can no longer require credit card as the only payment method, must get consent before using electronic funds transfer, and cannot charge a fee just to send an automated clearinghouse payment.
AIHealth insurers and HMOs cannot deny a claim for a procedure that was specifically included in a prior authorization when the claim comes from a physician licensed under chapter 458 or 459, not just from a dentist, unless a listed exception applies.
AIMedicaid managed care contracts previously could send provider disputes through the statewide process at the agency's option. This bill requires it: every dispute between a managed care plan and a provider must now be resolved that way.
AIPreviously any claim tied to a pending court case was excluded from review, letting a party use litigation to escape the process. Now only a lawsuit already filed over that specific claim, before it reaches the resolution organization, qualifies for exclusion.
AIA health plan or provider that simply declines to take part in the review process can no longer escape a default finding that way; refusing to participate is not a valid way to avoid default.
AIDisputes over paying a nonparticipating provider for emergency or nonemergency services still may go to court, but the alternative dispute process referenced in this section is now called mandatory rather than voluntary, matching the statewide program's new mandatory status.