Provide physician fee schedules electronically on request

Upon request, each insurer shall provide electronically a physician's fee schedule to any participating provider with whom the insurer has contracted for up to 100 CPT codes; this must be done within six months of the Act's effective date. The insurer may provide the schedule by CD-ROM or electronically and a physician may elect a hard copy instead (insurer may charge a reasonable fee for hard copy).

• Must be provided electronically (or by CD-ROM) upon written request from a physician who is a participating provider.
• Covers up to 100 CPT codes.
• Insurer must comply within six months of the Act's effective date.
• Physician may elect hard copy; insurer may charge a reasonable fee for hard copy.

Summary of recorded legislative actions

The legislative history lists introductions, readings, amendments, committee referrals, scrivener's corrections, enrollment, and the governor's signing as part of the recorded actions (entries reference SJ-18, SJ-308, R 374 and multiple journal entries).

• Records include introductions, second and third readings, committee referral to Senate Banking and Insurance, amendments, and scrivener's corrections.
• Journal references cited include SJ-18 and SJ-308 R 374.

Legislative history: signature and effective date

The legislative history records concurrence in House amendment and enrollment, scrivener's corrections, the governor's signature, and the effective date for the Act (signed by Governor; effective date recorded as 06/11/09).

• Concurrence and enrollment recorded as SJ-308 R 374.
• Scrivener's errors corrected and governor's signature noted.
• Effective date recorded as 06/11/09.

Provide contracted fee schedules to requesting physicians (up to 100 CPTs)

Upon written request, an insurer must provide the contracted fee schedule to a physician for up to 100 CPT codes; the physician may elect to receive a hard copy in lieu of electronic delivery, and the insurer may charge a reasonable fee to cover hard-copy administrative costs. The fee schedule information must be kept confidential and disclosed only to staff with a need-to-know; failure to maintain confidentiality may forfeit the physician's right to receive schedules.

• Physician may request schedule twice annually.
• Insurer may provide electronically or by CD-ROM at its option, or provide hard copy if requested (reasonable fee allowed).
• Disclosure limited to employees with need-to-know; confidentiality obligations required or physician may forfeit right to receive schedules.

Do not convert provider electronic claims into paper claims

A billing agent or any entity that contracts with a provider to deliver claims to an insurer is prohibited from converting electronic claims submitted by the provider into paper claims for submission to the insurer; a violation constitutes an unfair trade practice and gives rise to an action as set forth in Section 39-5-140.

• Prohibition applies to billing agents and other contractors delivering claims on a provider's behalf.
• Violations are actionable and treated as unfair trade practices under Chapter 5, Title 39.

Send 30-business-day written notice before overpayment recovery

Before initiating overpayment recovery (other than for duplicate payments or similar adjustments), an insurer shall send a written notice to the provider at least thirty business days prior to commencing recovery efforts.

• Notice must be written and provided at least 30 business days before recovery efforts begin, except for duplicate payments and other enumerated adjustments.
• Required notice contents (see related block): patient name, service date, payment amount, and a reasonably specific explanation of the change in payment.

Prohibition on converting provider electronic claims (billing agents/contractors)

A billing agent or contractor is explicitly prohibited from converting electronic claims submitted by a provider into paper claims for submission to the insurer; such conversion is an unfair trade practice and subject to enforcement and actions by injured providers and insurers.

• Applies to any entity that contracts with a provider to deliver claims to an insurer.
• Violation constitutes an unfair trade practice and may give rise to an action under Section 39-5-140.

Overpayment recovery notice contents and timing limits

The written notice required before overpayment recovery must include the patient's name, the service date, the payment amount received by the provider, and a reasonably specific explanation of the change in payment; the insurer may not initiate recovery more than eighteen months after the initial payment except for specified exceptions (fraud, self-insured plan requirements, or state/federal program requirements).

• Required notice contents: patient name; service date; payment amount received; reasonably specific explanation of change in payment.
• Insurer may not initiate recovery more than 18 months after initial payment, except for fraud, self-insured plan obligations, or state/federal program requirements.