MI HB4192

Health plans are prohibited from retrospectively denying previously paid claims to health professionals unless written notice is provided specifying the claim and reason for denial.

Retrospective denials of paid claims must occur within 12 months of payment, except for five specific circumstances: fraudulent submission, duplicate payment, coverage by Medicare/Medicaid/CHIP, coordination of benefits adjustments, or claims subject to legal action.

Health plans cannot reduce other payments, withhold future payments, or offset claims against health professionals except for the specific claim being retrospectively denied.

Health plans cannot retrospectively deny claims for which benefits or eligibility were verified by the health plan at the time services were provided.

For coordination of benefits denials, health plans must provide written notice to the health professional specifying which other plan or payor is responsible and the submission address.