An Act To O Prohibit Health Insurance Carriers from Retroactively Reducing Payment on Clean Claims Submitted by Pharmacies
Maine Legislature, Session 129, LD 1928
Committee Amendment CA_A_S434 (Senate)
Amends: 24-A MRSA §4317

COMMITTEE AMENDMENT " 
to S.P. 670, L.D. 1928, Bill, "An Act To 
O 
Prohibit Health Insurance Carriers from Retroactively Reducing Payment on Clean 
Claims Submitted by Pharmacies" 
Amend the bill by striking out everything after the enacting clause and inse1iing the 
following: 
'Sec. 1. 24-A MRSA §4317, sub-§2, as enacted by PL 2009, c. 519, §1 and 
affected by §2, is amended to read: 
2. 
Prompt payment of claims. 
Notwithstanding section 2436, the following 
provisions apply to the payment of claims submitted to a carrier by a pharmacy provider. 
A. For purposes of this subsection, the following terms have the following meanings. 
(1) "Applicable number of calendar days" means: 
(a) With respect to claims submitted electronically, 21 days; and 
(b) With respect to claims submitted otherwise, 30 days. 
(2) "Clean claim" means a claim that has no defect or impropriety, including any 
lack of any required substantiating documentation, or particular circumstance 
requiring special treatment that prevents timely payment from being made on the 
claim under this section. 
B. A contract entered into by a carrier with a pharmacy provider with respect to a 
prescription drug plan offered by a carrier must provide that payment is issued, 
mailed or otherwise transmitted with respect to all clean claims submitted by a 
pharmacy provider, other than a pharmacy that dispenses drugs by mail order only or 
a pharmacy located in, or under contract with, a long-term care facility, within the 
applicable number of calendar days after the date on which the claim is received. For 
purposes of this subsection, a claim is considered to have been received: 
(1) With respect to claims submitted electronically, on the date on which the 
claim is transferred; and 
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"to S.P. 670, L.D. 1928 
(2) With respect to claims submitted otherwise, on the 5th day after the postmark 
date of the claim or the date specified in the time stamp of the transmission of the 
claim. 
C. If payment is not issued, mailed or otherwise transmitted by the carrier within the 
applicable number of calendar days after a clean claim is received, the carrier shall 
pay interest to the pharmacy provider at the rate of 18% per annum. 
D. A claim is considered to be a clean claim if the carrier involved does not provide 
notice to the pharmacy provider of any deficiency in the claim within 10 days after 
the date on which an electronically submitted claim is received or within 15 days 
after the date on which a claim submitted otherwise is received. 
E. If a carrier determines that a submitted claim is not a clean claim, the carrier shall 
immediately notify the pharmacy provider of the determination. The notice must 
specify all defects or improprieties in the claim and list all additional information or 
documents necessary for the proper processing and payment of the claim. If a 
pharmacy provider receives notice from a carrier that a claim has been determined to 
not be a clean claim, the pharmacy provider shall take steps to correct that claim and 
then resubmit the claim to the carrier for payment. 
F. A claim resubmitted to a carrier with additional information pursuant to paragraph 
E is considered to be a clean claim if the carrier does not provide notice to the 
pharmacy provider of any defect or impropriety in the claim within IO days of the 
date on which additional information is received if the claim is resubmitted 
electronically or within 15 days of the date on which additional information is 
received if the claim is resubmitted otherwise. 
G. A claim submitted to a carrier that is not paid by the carrier or contested by the 
plan sponsor within the applicable number of calendar days after the date on which 
the claim is received by the carrier is considered to be a clean claim and must be paid 
by the carrier. 
H. Payment of a clean claim under this subsection is considered to have been made 
on the date on which the payment is transferred with respect to claims paid 
electronically and on the date on which the payment is submitted to the United States 
Postal Service or common carrier for delivery with respect to claims paid otherwise. 
I. A carrier shall pay all clean claims submitted electronically by electronic transfer 
of funds if the pharmacy provider so requests or has so requested previously. In the 
case when the payment is made electronically, remittance may be made by the carrier 
electronically. 
J. For a contract entered into or renewed on or after January 1, 2021, the contract 
entered into by a carrier with a pharmacy provider with respect to a prescription drug 
plan offered by a carrier may not contain a provision that purports to directly or 
indirectly charge the pharmacy provider or hold the pharmacy provider responsible 
for any fee related to a clean claim: 
(1) That is not apparent at the time the carrier processes the claim; 
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(2) That is not repo1ied on the remittance advice of a claim adjudicated by the 
carrier; or 
(3) After the initial claim is adjudicated by the carrier. 
For purposes of this subsection, a contract entered into by a carrier with a pharmacy 
provider with respect to a prescription drug plan offered by a carrier includes any contract 
with respect to a prescription drug plan offered by the carrier under which a phannacy 
provider is legally obligated, either directly or through an intermediary.' 
Amend the bill by relettering or renumbering any nonconsecutive Part letter or 
section number to read consecutively. 
SUMMARY 
This amendment replaces the bill and is the majority report of the committee. The 
amendment prohibits a contract between a carrier and a pharmacy provider that is entered 
into or renewed on or after January 1, 2021 from containing a provision that purp01is to 
directly or indirectly charge the pharmacy provider or hold the pharmacy provider 
responsible for any fee related to a claim that is not apparent at the time the carrier 
processes the claim, that is not reported on the remittance advice or after the initial claim 
is adjudicated. The amendment also clarifies that the provision applies to any contract 
with respect to a prescription drug plan offered by the carrier under which a pharmacy 
provider is legally obligated, either directly or through an intermediary. 
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