TITLE 27
Insurance

CHAPTER 27-20.1
Nonprofit Dental Service Corporations

SECTION 27-20.1-19


§ 27-20.1-19 Post-payment audits.

(a) Except as otherwise provided herein, any review, audit or investigation by a nonprofit dental service corporation of a health care provider's claims which results in the recoupment or set-off of funds previously paid to the health care provider in respect to such claims shall be completed no later than two (2) years after the completed claims were initially paid. This section shall not restrict any review, audit or investigation regarding claims that are submitted fraudulently, are subject to a pattern of inappropriate billing, are related to coordination of benefits, or are subject to any federal law or regulation that permits claims review beyond the period provided herein.

(b) No health care provider shall seek reimbursement from a payer for underpayment of a claim later than two (2) years from the date the first payment on the claim was made, except if the claim is the subject of an appeal properly submitted pursuant to the payer's claims appeal policies or the claim is subject to continual claims submission.

(c) For the purposes of this section, "health care provider" means an individual clinician, either in practice independently or in a group, who provides health care services, and otherwise referred to as a non-institutional provider.

History of Section.
(P.L. 2006, ch. 86, § 4; P.L. 2006, ch. 97, § 4.)