An Act To Prohibit Insurance Carriers from Retroactively Reducing Payment on Clean Claims Submitted by Pharmacies
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §4317, sub-§2, ¶¶J and K are enacted to read:
J. A contract entered into by a carrier with a pharmacy provider with respect to a prescription drug plan offered by the carrier must provide that the carrier may not retroactively reduce payment directly, or indirectly reduce payment through an aggregated effective rate or otherwise, on a claim submitted by the pharmacy provider except for a claim determined by the carrier not to be a clean claim during the course of a routine audit conducted pursuant to the contract between the carrier and the pharmacy provider. This paragraph does not prohibit any retroactive increase in payment to the pharmacy provider pursuant to a contract between a carrier and the pharmacy provider.
K.
A contract entered into by a carrier with a pharmacy provider with respect to a prescription drug plan offered by the carrier must provide that the carrier may not directly or indirectly charge or hold the pharmacy provider responsible for any fee related to a claim:
(1) That is not apparent at the time the carrier processes the claim;
(2) That is not reported on the remittance advice of a claim adjudicated by the carrier; or
(3) After the initial claim is adjudicated by the carrier.
SUMMARY
This bill prohibits a health insurance carrier from retroactively reducing payment on a properly submitted claim by a pharmacy provider. The bill also prohibits a carrier from charging or holding a pharmacy provider responsible for any fee related to a claim that is not apparent at the time the carrier processes the claim, that is not reported on the remittance advice or after the initial claim is adjudicated by the carrier.