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 eighteen (18) months after the completed claims were initially paid. This section shall not restrict any review, audit, or investigation regarding claims that are submitted fraudulently, are known, or should have been known, by the health-care provider to be a pattern of inappropriate billing according to the standards for provider billing of their respective medical or dental specialty, 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 eighteen (18) months 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; P.L. 2017, ch. 368, § 5; P.L. 2017, ch. 375, § 5.)