An Act to Amend the Maine Insurance Code Regarding Payments by Health Insurance Carriers to Providers
Maine Legislature, Session 131, LD 1407
Committee Amendment CA_A_H790 (House)
Amends: 24-A MRSA §4303

COMMITTEE AMENDMENT "A" to H.P. 903, L.D. 1407, "An Act to Amend the 
Maine Insurance Code Regarding Payments by Health Insurance Carriers to Providers" 
Amend the bill by striking out everything after the enacting clause and insetting the 
following: 
'Sec. 1. 24-A MRSA §4303, sub-§9, as amended by PL 2021, c. 311, § 1, is fmther 
amended to read: 
9. Notice of amendments to provider agreements. A carrier offering or renewing a 
health plan in this State shall notify a paiticipating provider of a proposed amendment to a 
provider agreement at least 60 days prior to the amendment's proposed effective date and 
may file such notice of a proposed amendment to a provider agreement only 4 times per 
calendar year on January 1st, April 1st, July 1st and October 1st, except that, at any time, 
a carrier may file a notice of a proposed amendment in response to a requirement of the 
State or Federal Government or due to a change in current procedural terminology codes 
used by the American Medical Association. 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. If the change is to a 
reimbursement policy and the estimated aggregate change to pa1ticipating provider 
reimbursement as a result of the change is more than $500,000 per year, the notice must 
include the carrier's good faith estimate of the total annual financial impact of the 
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amendment on the aggregate amount of reimbursement payments made by the carrier to all 
providers within the State with whom the carrier has a provider agreement. 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 
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change at any time after the provider has received notice of the proposed amendment. If 
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COMMITTEE AMENDMENT 'A "to H.P. 903, L.D. 1407 
the notice required by this subsection is provided by electronic communication, the subject 
line of the electronic communication must indicate that notice of an amendment to a 
provider agreement or manual, policy or procedure document is included in the 
communication and the notice of the amendment must be provided as an attachment to the 
communication, as a separate document. As part of the notice required under this 
subsection, a carrier shall provide a copy of the revised provider agreement, manual, policy 
or procedure document without changes being noted and a copy of the revised provider 
agreement, manual, policy or procedure document with changes being noted by underlining 
added language and by striking through deleted language. 
Sec. 2. 24-A MRSA §4303, sub-§10, as amended by PL 2007, c. 106, § 1, is further 
amended to read: 
10. Limits on retrospective denials. -A. Except as provided in paragraphs C and D, 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+ the carrier 
has provided the reason for the retrospective denial in writing to the provider and the time 
that has elapsed since the date of payment of the previously paid claim does not exceed 12 
months. 
A. The earrier 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 exeeed 12 months. The retrospeetive denial of a previously paid claim may 
be permitted beyond 12 months from the date of payment only for the following 
reasons: 
(1) The claim v,ras submitted fraudulently; 
(2) The claim payment 1.vas inoorreot beoause the provider or the insured was 
already paid for the health eare serviees identified in the claim; 
(3) The health care serviees identified in the claim were not delivered by the 
provider; 
(4) The elaim payment v1as for services severed by Title XVIII, Title XIX or Title 
X.XI of the Sooial Security l.cot; 
(5) 
The claim payment is the subjeet of adjustment 1Nith at~other insurer, 
administrator or payer; or 
(6) The claim payment is the subject of legal action. 
C. The retrospective denial of a previously paid claim may be permitted from 12 
months from the date of payment until no later than 36 months from the date of 
payment for the following reasons only: 
(1) The claim payment was incorrectly made because the provider or the insured 
was already paid in full for the health care services identified in the claim; 
(2) The health care services identified in the claim were not delivered by the 
provider; 
(3) 
The claim payment is the subject of adjustment with another insurer, 
administrator or payor; or 
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COMMITTEE AMENDMENT "A" to H.P. 903, L.D. 1407 
(4) The claim payment is the subject of legal action. 
D. The retrospective denial of a previously paid claim may be permitted beyond 12 
months from the date of payment for the following reasons only: 
(1) The claim was submitted fraudulently; or 
(2) The claim payment was for services covered by Title XVIII, Title XIX or Title 
XXI of the Social Security Act. 
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 requiring repayment of such payments, reducing other payments 
currently owed to the provider, withholding or setting off against future payments or 
reducing or affecting the reimbursement rates for 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 tenns 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 tern1ination of coverage.' 
Amend the bill by relettering or renumbering any nonconsecutive Part letter or section 
number to read consecutively. 
SUMMARY 
This amendment replaces the bill. The amendment makes the following changes to the 
Maine Insurance Code. 
1. It provides that a health insurance carrier may file notice of a proposed amendment 
to a calendar year provider agreement only 4 times per year on January 1st, April 1st, July 
1st and October 1st, except for changes in response to a requirement of the State or Federal 
Government or due to a change in current procedural terminology codes used by the 
American Medical Association. 
2. It requires a health insurance carrier in certain cases to include an estimate of any 
adverse financial impact on a pa1ticipating provider as patt of a notice of an amendment to 
a provider agreement if the change is to a reimbursement policy. 
3, It requires a health insurance carrier to provide to the pa1ticipating provider both a 
clean and a marked-up copy of the provider agreement, manual, policy or procedure 
document being changed. 
4. It restricts the authority of a health insurance carrier in ce1tain cases to retroactively 
deny a previously paid claim to no later than 36 months from the date of the claims 
payment. 
COMMITTEE AMENDMENT