An Act To Regulate Insurance Carrier Concurrent, Prepayment and Postpayment Review
Maine Legislature, Session 130, LD 1317
Committee: Health Coverage, Insurance and Financial Services
Sponsors: BRENNER, CLAXTON, KEIM, POULIOT, SANBORN, BROOKS, MEYER, PERRY, QUINT
Amends: 24-A MRSA §4303

Legislative Document
No. 1317
S.P. 423
In Senate, March 29, 2021
An Act To Regulate Insurance Carrier Concurrent, Prepayment 
and Postpayment Review
Reference to the Committee on Health Coverage, Insurance and Financial Services 
suggested and ordered printed.
DAREK M. GRANT
Secretary of the Senate
Presented by Senator BRENNER of Cumberland.
Cosponsored by Senators: CLAXTON of Androscoggin, KEIM of Oxford, POULIOT of 
Kennebec, SANBORN of Cumberland, Representatives: BROOKS of Lewiston, MEYER of 
Eliot, PERRY of Calais, QUINT of Hodgdon.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24-A MRSA §4303, sub-§24 is enacted to read:
24.  Provider audits or reviews.  Any audit or review of the documentation or records 
of a provider conducted by a carrier for the purposes of identifying fraud, waste or abuse, 
determining whether the documentation is appropriate or adequate to support a claim for 
covered health care services or determining whether health care services are or were 
medically necessary as a condition of payment must be conducted in accordance with the 
following requirements.
A.  The requirements of this subsection apply whether the audit or review is performed 
prior to payment, concurrently with any payment or following any payment made by 
the carrier.
B.  When a carrier subjects a provider to prepayment review, the carrier shall have a 
process to allow claims and documentation to be submitted to the carrier electronically 
for purposes of proving timely filing and tracking the carrier's compliance with time 
limits in other applicable laws.
C.  Any audit or review must be conducted by a clinical peer licensed in this State to 
practice in the same profession as the provider being audited. The clinical peer who 
performs the audit or review is the sole contact person for the provider if the provider 
has any questions related to an audit or review, denial or nonpayment of a claim.  Any 
records of an individual enrollee reviewed as part of the audit or review must be 
reviewed by the same clinical peer. 
D.  A carrier may not apply additional or different documentation standards beyond the 
minimum licensing requirements for the profession of the provider being audited or 
reviewed.
E.  A carrier may not deny payment of a claim for covered health care services by a 
provider solely on the basis of a minor documentation error or omission, including, but 
not limited to, misspelling, use of an abbreviation or a correctable error.  If an error or 
omission is the basis of a disputed claim, the carrier shall allow the provider or enrollee 
an opportunity to correct the error or omission and then adjudicate the claim.
F.  Claims subject to a prepayment review must be paid or disputed within 30 days as 
required by section 2436 and consistent with retrospective review decisions under 
Bureau of Insurance rule Chapter 850, Health Plan Accountability. Any claim that is 
not disputed pursuant to section 2436, subsection 2 or paid within 30 days by the carrier 
is overdue and subject to interest in accordance with section 2436 and Bureau of 
Insurance rule Chapter 850, Health Plan Accountability.
G.  For purposes of this subsection, claims subjected to prepayment review that are 
denied or disputed must be treated as an adverse health care treatment decision and 
both provider and enrollee are entitled to the same appeal procedures as a retrospective 
review decision under Bureau of Insurance rule Chapter 850, Health Plan 
Accountability.
H.  If a carrier requires additional information as part of an audit or to adjudicate a 
claim for covered health care services by a provider, the carrier shall inform the 
provider of the precise information needed by the carrier to adjudicate the claim and 
any general statement such as "attachment is needed" without stating which attachment 
is needed or "claim lacks information" without stating which information is required is 
not sufficient. 
I.  Any additional information submitted by a provider as required by a carrier is 
considered timely filed as of the date the original claim was submitted by the provider. 
J.  If a claim is denied by a carrier, the carrier shall provide accurate information on 
how a provider may appeal the claim on behalf of an enrollee, including the address 
where a written appeal should be sent. All rights to appeal denied or unpaid claims 
afforded to an enrollee under Bureau of Insurance rule Chapter 850, Health Plan 
Accountability apply to any appeal made by a provider on an enrollee's behalf, 
including the rights provided in section 4312.
K.  A carrier shall provide an appeal process for any provider placed on prepayment 
review and remove the provider from prepayment review if or when the carrier cannot 
prove the provider committed fraud, waste or abuse, miscoded services or did not 
support the medical necessity of the provider's claims in the provider's documentation 
on a routine basis pursuant to an audit or review that meets the requirements of this 
subsection.  
L.  When an enrollee designates a provider as the enrollee's authorized representative 
in writing for purposes of filing appeals and complaints against a carrier, the 
superintendent shall consider any such provider appeals and complaints as if they were 
filed by the enrollee without requiring any additional action by the enrollee. 
M.  A carrier may not audit a provider or require that a provider's claims are subject to 
prepayment review as retribution for raising contract disputes.
For the purposes of this subsection, "prepayment review" means any review or audit 
process of a provider's claims by a carrier, or the carrier's agent, for an evaluation of 
reimbursement levels, veracity of documentation, accuracy of coding, adjudication for 
payment or utilization review of the appropriateness, quality or medical necessity of health 
care services prior to making payment to a provider.
Sec. 2.  Application.  This Act applies to any claim that has been subjected to 
prepayment review as described in the Maine Revised Statutes, Title 24-A, section 4303, 
subsection 24 that has not yet been resolved as of the effective date of this Act and to any 
claim submitted by a provider subject to audit or review on or after the effective date of 
this Act.
SUMMARY
This bill establishes requirements for carriers performing audits or documentation 
reviews of claims for payment made by providers for covered health care services. The 
requirements apply whether the audit or review is performed prior to payment, concurrently 
with any payment or following any payment made by the carrier.