2017 District of Columbia Code
Title 31 - Insurance and Securities.
Chapter 31A - Health Benefits Plans Prompt Payment.
§ 31–3133. Retroactive denial of reimbursement.

(a) A health insurer may only retroactively deny reimbursement to a health care provider:

(1) For services subject to coordination of benefits with another health insurer during the 18-month period after the date that the health insurer paid the health care provider; or

(2) Except as provided in paragraph (1) of this subsection, during the 6-month period after the date that the health insurer paid the health care provider.

(b)(1) A health insurer that retroactively denies reimbursement to a health care provider under subsection (a)(1) of this section shall provide the health care provider with a written statement specifying the basis for the retroactive denial. If the retroactive denial of reimbursement results from coordination of benefits, the written statement shall provide the name and address of the entity acknowledging responsibility for payment of the denied claim.

(2) This subsection shall not apply if a health insurer retroactively denies reimbursement to a health care provider because:

(A) The information submitted to the health insurer was fraudulent;

(B) The information submitted to the health insurer was improperly coded and the health insurer has provided to the health care provider sufficient information regarding the coding guidelines used by the health insurer at least 30 days prior to the date the services subject to the retroactive denial were rendered; or

(C) The claim submitted to the health insurer was a duplicate claim.

(3) Information submitted to the health insurer may be considered to be improperly coded under paragraph (1) of this subsection if the information submitted to the health insurer by the health care provider:

(A) Uses codes that do not conform with the coding guidelines used by the health insurer applicable as of the date that services were rendered; or

(B) Does not otherwise conform with the contractual obligations of the health care provider to the health insurer applicable as of the date that services were rendered.

(c) If a health insurer retroactively denies reimbursement for services as a result of coordination of benefits, the health care provider shall have 180 days after the date of denial, unless the health insurer permits a longer time period, to submit a claim for reimbursement for the service to the health insurer responsible for payment.

(d) A health insurer that retroactively denies reimbursement to a health care provider under this section shall provide the health care provider with a written statement specifying the basis for the retroactive denial.

(e) This section shall not apply to an adjustment to reimbursement made as part of an annual contracted reconciliation of a risk-sharing arrangement.

(July 23, 2002, D.C. Law 14-176, § 4, 49 DCR 5086.)

This section is referenced in § 31-3138.