An Act Concerning Health Insurance Reimbursement and Contracting Practices LR1576(02)
Maine Legislature, Session 121, LD 0897
Committee Amendment CA_A_S90 (Senate)
Amends: 24-A MRSA §2680, 24-A MRSA §2753, 24-A MRSA §2823-B

COMMITTEE AMENDMENT" 
"to S.P. 292, L.D. 897, Bill, "An 
Act Concerning Health Insurance Reimbursement 
and Contracting 
Practices" 
Amend the bill by striking out everything after the enacting 
clause and before the summary and inserting in its place the 
following: 
. Sec. 1. 24 l\IlRSA §2332-E, as enacted by PL 1993, c. 477, Pt. 
D, §5 and affected by Pt. F, §1, is amended to read: 
§2332-E. Standardized claim fonns 
QB-e£-~~~-~--~r-~~~~r-a~~ All nonprofit hospital or 
medical service organizations and nonprofit health care plans 
providing payment or reimbursement for diagnosis or treatment of 
a 
condition 
or 
a 
complaint 
by 
a 
licensed 
physician 
or 
chiropractor must accept the current standardized claim form for 
professional services approved by the Federal Government. 
QB-e~ 
a~seF-~--±T-...J:..9.9-3-r--a±l All nonprofit hospital or medical 
service organizations and nonprofit health care plans providing 
payment 
or 
reimbursement 
for 
diagnosis 
or 
treatment 
of 
a 
condition or a complaint by a licensed hospital must accept the 
current standardized claim form 
for professional or facility 
services, as applicable, approved by the Federal Government. 
b. 
nonprofit hospital or medical service organization or nonprofit 
health care plan may not be required to accept a claim submitted 
on 
a 
form other than the applicable form specified in this 
section. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to S.P. 292, L.D. 897 
Sec. 2. 24·A MRSA §1912, as enacted by PL 1993, c. 477, Pt. 
0, §8 and affected by Pt. F, §l, is amended to read: 
§1912. Standardized c1aim forms 
G:a--o-r--a~t:e!'--Deaembe-r--±T--1-9-9-3-,--al± All administrators who 
administer claims and who provide payment or reimbursement for 
diagnosis or treatment of 
a 
condition or 
a 
complaint by 
a 
licensed 
physician 
or 
chiropractor 
must 
accept 
the 
current 
standardized claim form for professional services approved by the 
Federal 
Government. 
G:a--9~-~~~~-~--~~--~~~~7--a±± All 
administrators who administer claims and who provide payment or 
reimbursement for diagnosis or treatment of a condition or a 
complaint 
by 
a 
licensed 
hospital 
must 
accept 
the 
current 
standardized claim form for professional or facility services, as 
applicable, approved by the Federal Government. 
An administrator 
may not be required to accept a claim submitted on a form other 
than the applicable form specified in this section. 
Sec. 3. 24·A MRSA §2436, sub·§2·A, as enacted by PL 2001, c. 
569, §l, is amended to read: 
2-A. 
~e!' 
Except 
as 
provided 
in this 
subsection, 
for 
purposes of this section, an "undisputed claim" means a timely 
claim for payment of covered health care expenses under a policy 
or certificate providing health care coverage that is submitted 
to an insurer on the insurer's standard claim form using the most 
current published procedural codes with all the required fields 
completed with correct and complete information in accordance 
wi th the insurer's published claims filing requirements. After 
January 
1, 
2005, 
for 
a 
provider 
with 
or 
more 
full-time-equivalent employees, 
an "undisputed claim" means 
a 
timely claim for payment of covered health care expenses under a 
policy or certificate providing health care coverage that is 
submitted to an insurer in the insurer's standard electronic data 
format using the most current published procedural codes with all 
the 
required 
fields 
completed 
with 
correct 
and 
complete 
information in accordance with the insurer's published claims 
filing requirements. 
This subsection applies only to a policy or 
certificate of 
a 
health plan as defined in section 4301-A, 
subsection 7. 
Sec. 4. 24·A MRSA §2436, sub·§3, as amended by PL 1999, c. 
256, Pt. I, §l, is further amended to read: 
3. 
If an insurer fails to pay an undisputed claim or any 
undisputed part of the claim when due, the amount of the overdue 
claim or part of the claim bears interest at the rate of 1 1/2% 
per month after the due date. 
Notwithstanding this subsection, 
COMMITTEE AMENDMENT 
.. ,. 
~. 
COMMITTEE AMENDMENT 
to S.P. 292, L.D. 897 
the superintendent may 
adopt rules that establish a 
minimum 
amount of interest payable on an overdue undisputed claim to a 
health care provider before a 
payment must be issued. 
Rules 
adopted pursuant to this subsection are routine technical rules 
as defined in Title 5, chapter 375, subchapter 2-A. 
Sec. 5. 24-A MRSA §2680, as repealed and replaced by PL 1999, 
c. 609, §18, is amended to read: 
§2680. Standardized claim form 
Administrators 
providing 
payment 
or 
reimbursement 
for 
diagnosis or treatment of 
a 
condition or 
a 
complaint by 
a 
licensed physician, 
chiropractor 
or 
licensed 
hospital 
shall 
accept the current standardized claim form for professional or 
facility services, as applicable, approved by the 
~eeeFal-Real~R 
bat=e----F-inano-in9----A9.HI4a4s~l'a~4ea 
Federal 
Government. 
An 
administrator may not be reguired to accept a claim submitted on 
a form other than the applicable form specified in this section. 
Sec. 6. 24-A MRSA §2753, as enacted by PL 1993, c. 477, Pt. 
D, §10 and affected by Pt. F, §l, is amended to read: 
§2753. Standardized claim forms 
Ga--e~--~~~--~---~r--199~T All 
insurers 
providing 
individual medical expense insurance on an expense-incurred basis 
providing payment or reimbursement for diagnosis or treatment of 
a 
condition 
or 
a 
complaint 
by 
a 
licensed 
physician 
or 
chiropractor must accept the current standardized claim form for 
professional services approved by the Federal Government. 
GB-et= 
a~~el'-~F-..;],..,---l..g~"7--all-
A11 insurers providing individual 
medical expense insurance on an expense-incurred basis providing 
payment 
or 
reimbursement 
for 
diagnosis 
or 
treatment 
of 
a 
condition or a complaint by a licensed hospital must accept the 
current standardized claim form for professional or facility 
services, as applicable, approved by the Federal Government. 
An 
insurer may not be required to accept a claim submitted on a form 
other than the applicable form specified in this section. 
Sec. 7. 24-A MRSA §2823-B, as enacted by PL 1993, c. 477, Pt. 
D, §ll and affected by Pt. F, §l, is amended to read: 
§2823-B. Standardized claim forms 
GB-~--a~~eF--De-oembe-l"--lT--1-9-9-3-,--ald: All insurers providing 
group medical 
expense insurance on an expense-incurred basis 
providing payment or reimbursement for diagnosis or treatment of 
a 
condition 
or 
a 
complaint 
by 
a 
licensed 
physician 
or 
chiropractor must accept the current standardized claim form for 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "~,, to S.P. 292, L.D. 897 
professional services approved by the Federal Government. 
Qa-e~ 
af~eF-~~-~'--~~~~r-all All insurers providing group medical 
expense insurance on an expense-incurred basis providing payment 
or reimbursement for diagnosis or treatment of a condition or a 
complaint 
by 
a 
licensed 
hospital 
must 
accept 
the 
current 
standardized claim form for professional or facility services, as 
applicable, approved by the Federal Government. 
An insurer may 
not be required to accept a claim submitted on a form other than 
the applicable form specified in this section. 
Sec. 8. 24·A MRSA §4235, as enac ted by PL 1993, c. 477, Pt. 
D, §12 and affected by Pt. F, §1, is amended to read: 
§4235. Standardized claim forms 
Qa--<H:'--aEt:.e~-~--lT--J:.9.9.-3-,--a:ll All health maintenance 
organizations providing payment or reimbursement for diagnosis or 
treatment of a condition or a complaint by a licensed physician 
or chiropractor must accept the current standardized claim form 
for professional services approved by the Federal Government. 
Qa 
eF--~Ft~---~e€effige£---~r--~~---all 
All 
health 
maintenance 
organizations providing payment or reimbursement for diagnosis or 
treatment of a condition or a complaint by a licensed hospital 
must accept the current standardized claim form for professional 
or facility services, 
as applicable, 
approved by the Federal 
Government. 
A 
health 
maintenance 
organization 
may 
not 
be 
required to accept a claim submitted on a form other than the 
applicable form specified in this section. 
Sec. 9. 24·A MRS A §4303, sub·§§9 and 10 are enacted to read: 
9. 
Notice of amendments to provider agreements. 
A carrier 
offering a health plan in this State shall notify a participating 
provider of a proposed amendment to a provider agreement at least 
days prior to the amendment's proposed effective date. 
If an 
amendment 
that 
has 
substantial 
impact 
on 
the 
rights 
and 
obligations of providers is made to a manual, policy or procedure 
document referenced in the provider agreement, such as material 
changes to fee schedules or material changes to procedural coding 
rules specified in the manual, policy or procedure document, the 
carrier shall provide 60 days' notice to the provider. 
After the 
60-day notice period has expired, the amendment to a manual, 
policy or procedure document becomes effective and binding on 
both the carrier and the provider subject to any applicable 
termination provisions in the provider agreement, except that the 
carrier and provider may mutually agree to waive the 60-day 
notice requirement. 
This subsection may not be construed to'· 
limit the ability of a carrier and provider to mutually agree to 
the proposed change at any time after the provider has received 
notice of the proposed amendment. 
COMMITTEE AMENDMENT 
• 
',. 
~~. 
COMMIITEE AMENDMENT ,A .. to S,p, 292, L,D. 897 
10. 
Limits on retrospective denials. 
A carrier offering a 
health plan in this State may not impose on any provider any 
retrospective denial of a previously paid claim or any part of 
that previously paid claim unless: 
A. 
The 
carrier 
has 
provided 
the 
reason 
for 
the 
retrospective denial in writing to the provider; and 
B. 
The time that has elapsed since the date of payment of 
the previously paid claim does not exceed 18 months. 
The 
retrospective denial of 
a 
previously paid claim may 
be 
permitted beyond 18 months from the date of payment only for 
the following reasons: 
(1) 
The claim was submitted fraudulently; 
(2) 
The 
claim 
payment 
was 
incorrect 
because 
the 
provider or the insured was already paid for the health 
care services identified in the claim; 
(3) 
The health care services identified in the claim 
were not delivered by the provider; 
(4) 
The claim payment was for services covered by 
Title XVIII, Title XIX or Title XXI 
of the Social 
Security Act; 
(5) 
The claim payment is the subject of adjustment 
with another insurer, administrator or payor; or 
(6) 
The claim payment is the subject of legal action. 
For purposes of this subsection, 
"retrospective denial of 
a 
previously paid 
claim" 
means 
any 
attempt 
by 
a 
carrier 
to 
retroactively collect payments already made to a provider with 
respect to a 
claim by requ1r1ng repayment of such payments, 
reducing 
other 
J?ayments 
currently 
owed 
to 
the 
provider, 
withholding or setting off against future payments or reducing or 
affecting the future claim payments to the provider in any other 
manner. 
The provider has 6 months from the date of notification 
under this subsection to determine whether the insured has other 
appropriate insurance that was in effect on the date of service. 
Notwithstanding the terms of the provider agreement, the carrier 
shall allow for the submission of a claim that was previously 
denied by another insurer because of the insured' s transfer or 
termination of coverage.' 
COMMITTEE AMENDMENT 
.~, 
~~. 
COMMITTEE AMENDMENT "A" to S.P. 292, L.D. 897 
SUMMARY 
The 
amendment 
replaces the bill. The 
amendment requires 
health carriers to give providers 60 days' notice of substantive 
amendments to provider agreements with certain exceptions. The 
parties may waive the notice requirement by mutual agreement. The 
amendment 
further 
requires 
limits 
on 
health 
insurers' 
retrospective denials of previously paid claims to 18 months from 
the date of payment with certain exceptions. 
The 
amendment 
permi ts carriers to refuse to accept claims not submitted on 
standardized claim forms approved by the Federal Government. 
The 
amendment 
requires 
that 
providers 
with 
or 
more 
full-time-equivalent 
employees 
file 
claims 
electronically 
in 
order to claim interest, pursuant to the statute requiring health 
insurers to pay interest if an undisputed claim is not paid 
within 30 days of submission, beginning in 2005. 
Finally, it 
permits the Superintendent of Insurance to adopt rules that set a 
m~n~murn amount of interest payable to health care providers, 
pursuant to the statute requiring health insurers to pay interest 
if an undisputed claim is not paid within 30 days of submission, 
before a payment must be issued. 
FISCAL NOTE REQUIRED 
(See attached) 
COMMITTEE AMENDMENT 
, 
Fiscal Detail and Notes 
Approved: 04/22/03 ~ae 
Office of Fiscal and Program Review 
LD897 
An Act Concerning Health Insurance Reimbursement and Contracting 
Practices 
LR1576(02) 
Fiscal Note for Bill as Amended by Committee Amendment 1f' 5>,qo 
Committee: Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
Minor cost increase - Other Special Revenue Funds 
Any additional costs to the Department of Professional and Financial Regulation can be absorbed by the Department 
utilizing existing budgeted resources. 
LR1576(2) - Fiscal Note - PaQe 1 of 1