Connecticut law limits health plans' reversal of provider payments

Covered organizations may cancel, deny, or demand repayment for an authorized service because of an administrative or eligibility error only within 12 months of receiving a clean claim. The rule covers contracting health organizations and listed insurers and other entities providing specified individual or group health coverage in Connecticut. The time limit has exceptions for a documented belief that a provider submitted a fraudulent claim, improper billing based on the service provided, duplicate payment, payment that should have come from a federal or state program, or payment from another insurer or specified coverage. The text makes the provision in section 2 effective January 1, 2027. Section 1 states no separate effective date in the supplied text.

Covered organizations must give providers advance notice of a cancellation, denial, or repayment demand, and providers may appeal. These rules apply when a contracting health organization or covered insurer cancels, denies, or demands repayment from a provider. A repayment demand must pause while an appeal is pending. If the organization does not report its decision within 30 business days after receiving the appeal, the appeal is decided in the provider's favor. Organizations have 30 business days after receiving an appeal to report a decision. If there is no appeal or an appeal is denied, providers generally have 30 days to resubmit an adjusted claim; they may not resubmit a claim for duplicate payment.

A provider may identify other insurance that covered the patient on the service date and file a claim with that insurer. This applies to providers receiving notice of a cancellation, denial, or repayment demand under the covered health insurance rules. The claim may be filed even if the other insurer's usual filing deadline has passed. A provider may also have one year to submit an adjusted claim to the organization as a secondary payer when another insurer or specified coverage paid the claim. The year to identify other coverage and file a claim runs from the written notice. A separate year for an adjusted secondary-payer claim runs from the cancellation, denial, or repayment.