STATE OF OKLAHOMA

1st Session of the 52nd Legislature (2009)

SENATE BILL 1004	By:	Easley

AS INTRODUCED

An Act relating to insurance; defining terms; providing that an insurer shall not impose a retrospective denial of a previously paid claim unless certain conditions are met; providing for codification; and providing an effective date.

BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6585 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  For purposes of this section:
1.  “Health care provider” means any person, firm, corporation or other legal entity that is licensed, certified or otherwise authorized by the laws of this state to provide health care services, procedures or supplies in the ordinary course of business or practice of a profession; and
2.  “Insurer” means any insurance company, not-for-profit hospital service and medical indemnity plan, health insurance service organization, preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state.
B.  An insurer shall not impose on any health care provider any retrospective denial of a previously paid claim or any part of that previously paid claim, unless:
1.  The insurer has provided at least thirty (30) days’ notice of any retrospective denial or overpayment recovery or both in writing to the health care provider.  The notice shall include:
a.	the patient’s name, 
b.	the service date,
c.	the payment amount, 
d.	the proposed adjustment, and
e.	a reasonably specific explanation of the proposed adjustment;
2.  The time that has elapsed since the date of payment of the previously paid claim does not exceed twelve (12) months; and
3.  The retrospective denial of a previously paid claim shall be permitted beyond twelve (12) months from the date of payment for any of the following reasons:
a.	the claim was submitted fraudulently,
b.	the claim payment was incorrect because the provider of the insured was already paid for the health services identified in the claim,
c.	the health care services identified in the claim were not delivered by the health care provider, and 
d.	the claim payment is the subject of adjustment with another health insurer and the other health insurer had paid the claim, and the claim payment is the subject of legal action.
SECTION 2.  This act shall become effective November 1, 2009.

52-1-814	ARE	1/15/2009 3:00:41 PM