An Act To Regulate Insurance Carrier Concurrent, Prepayment and Postpayment Review
Maine Legislature, Session 130, LD 1317
Committee Amendment CA_A_S207 (Senate)
Amends: 24-A MRSA §4303

COMMITTEE AMENDMENT" f-r "to S.P. 423, L.D. 1317, "An Act To Regulate 
Insurance Carrier Concurrent, Prepayment and Postpayment Review" 
Amend the bill by striking out the title and substituting the following: 
'An Act To Regulate Insurance Carrier Practice or Facility-wide Prepayment Review' 
Amend the bill by striking out everything after the enacting clause and inserting the 
following: 
'Sec. 1. 24-A MRSA §4303, sub-§24 is enacted to read: 
24. Practice or facility-wide prepayment review of providers. A practice or 
facility-wide prepayment 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 health 
care as a condition of payment must be conducted in accordance with the following 
requirements. 
· 
A. 
When a carrier subiects a provider or facility to a practice or facility-wide 
prepayment review, the carrier shall provide 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. 
B. Claims subject to a practice or facility-wide prepayment review must be paid or 
disputed within 30 days as required by section 2436. Any claim that is not disputed 
pursuant to section 2436 or paid within 30 days by the carrier is overdue and subject to 
interest in accordance with section 2436. 
C. 
Any records of an enrollee reviewed as part of a practice or facility-wide 
prepayment review must be reviewed by the same reviewer to the extent possible. The 
reviewer who performs the practice or facility-wide prepayment review is the primary 
contact person for the provider related to an audit, review, denial or nonpayment of a 
Page I - 130LR1497(02) 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 423, L.D. 1317 (s--zo,J 
claim. Any practice or facility-wide prepayment review that involves clinical or 
professional iudgement must be conducted by or in consultation with a clinical peer. 
D. A carrier may not apply additional or different documentation standards beyond the 
standards set by the professional association of the provider subject to practice or 
facility-wide prepayment review if those standards are publicly available or made 
available to the carrier. This paragraph does not prohibit carriers from establishing or 
applying medical policies or clinical guidelines to determine whether a service is a 
covered benefit and medically necessary health care. This paragraph does not apply to 
claims submitted by a hospital or other health care facility. 
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, unless the 
carrier affords the provider or enrollee the opportunity to resubmit the claim to correct 
the identified error. 
F. If a carrier requires additional information as part of a practice or facility-wide 
prepayment review of a claim for covered health care services by a provider, the carrier 
shall inform the provider with reasonable specificity of the information needed by the 
carrier to adjudicate the claim. 
G. Additional information required by a carrier is considered timely filed by the 
provider if submitted within 30 days from the date the provider received notice from 
the carrier of the errors, omissions or additional information needed. 
H. A carrier shall provide information on how a provider may appeal the denial of a 
claim, including the mailing or e-mail address or fax number where an appeal should 
be sent on its publicly accessible website or in a provider manual. 
I. A carrier shall provide an opportunity to appeal the results of an audit leading to the 
provider being put on a practice or facility-wide prepayment review. 
J. A carrier may not audit a provider or require that a provider's claims be subiect to 
practice or facility-wide prepayment review as retribution for raising contract disputes. 
For the purposes of this subsection, "practice or facility-wide prepayment review" means a 
manual review or audit process of all. or substantially all, of a provider's claims by a carrier 
or the carrier's agent. 
Sec. 2. Application. This Act applies to any claim that has been subjected to practice 
or facility-wide 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 on or after the effective date of this Act.' 
Amend the bill by relettering or renumbering any nonconsecutive Part letter or section 
number to read consecutively. 
SUMMARY 
This amendment replaces the bill and establishes requirements for carriers performing 
practice or facility-wide prepayment review of claims for payment made by providers for 
covered health care services. The requirements apply to any claim of a provider that has 
been subjected to practice or facility-wide prepayment review that has not yet been resolved 
COMMITTEE AMENDMENT 
COMMITTEEAMENDMENT",4"to S.P. 423, L.D. 1317( S· w----5) 
as of the effective date of the bill and any claim submitted by a provider on or after the 
effective date of the legislation. 
FISCAL NOTE REQUIRED 
(See attached) 
COMMITTEE AMENDMENT 
Approved: 06/05/21 ;wac. 
LD 1317 
LR 1497(02) 
An Act To Regulate Insurance Carrier Concurrent, Prepayment and Postpayment Review 
Fiscal Note for Bill as Amended by Committee Amendment 'if' ( S -z 07 "j 
Committee: Health Coverage, Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
Minor cost increase - All Funds 
Fiscal Detail and Notes 
The requirements in this bill may increase costs to the State Employee Health Plan by minor amounts. Any costs 
would likely be reflected through changes in premium amounts in future fiscal years. Any additional costs to the 
Department of Professional and Financial Regulation are expected to be minor and can be absorbed within existin 
budgeted resources.