Section 4B. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise:
''Behavioral health services'', as defined in section 1 of chapter 175, or ''services''.
''Provider'', (i) a mental health clinic or substance use disorder treatment program licensed by the department of public health under chapters 17, 111, 111B or 111E; or (ii) a behavioral, substance use disorder or mental health professional who is licensed under chapter 112 and accredited or certified to provide services and who has provided services under an express or implied contract or with the expectation of receiving payment, other than co-payment, deductible or co-insurance, directly or indirectly from the commission or other entity.
''Retroactive claims denial'', as defined in section 1 of chapter 175.
(b) The commission or an entity with which the commission contracts to provide or manage health insurance benefits, including mental health and substance use disorder services, shall not impose a retroactive claims denial for behavioral health services on a provider unless: (i) less than 12 months have elapsed from the time of submission of the claim by the provider to the commission or other entity responsible for payment; (ii) the commission or other entity has furnished the provider with a written explanation of the reason for the retroactive claims denial and, where applicable, a description of additional documentation or any other corrective action required for payment of the claim; and (iii) where applicable, the commission or other entity responsible for payment allows the provider 30 days to submit additional documentation or to take any other corrective action required for payment of the claim.
(c) Notwithstanding subsection (b), a retroactive claims denial may be allowed after 12 months if: (i) the claim was submitted fraudulently; (ii) the claim, or services for which the claim was submitted, is the subject of legal action; (iii) the claim payment was incorrect because the provider or the insured was already paid for the health care services identified in the claim; or (iv) the health care services identified in the claim were not delivered by the provider.
(d) If a retroactive claims denial is imposed because the claim payment is subject to adjustment due to expected payment from a payer other than the commission or an entity with which the commission contracts to provide or manage health insurance benefits, including mental health and substance use disorder services, the commission or other entity shall notify the provider not less than 15 days before imposing the retroactive claims denial. The provider shall have 12 months from the date of denial to determine whether the claim is subject to payment by a secondary insurer; provided, however, that if the claim is denied by the secondary insurer due to the insured's transfer or termination of coverage, the commission shall allow for resubmission of the claim.
Structure Massachusetts General Laws
Part I - Administration of the Government
Title IV - Civil Service, Retirements and Pensions
Section 1 - Purpose of Chapter
Section 3 - Group Insurance Commission
Section 3a - Employees' Advisory Committee
Section 3b - Applicability of Chapter to Commonwealth Charter Schools and Education Collaboratives
Section 4 - Purchase of Insurance Policies by Commission
Section 4a - Administrative Services Contracts
Section 4b - Retroactive Claims Denials for Behavioral Health Services
Section 5 - Insurance and Medicare Benefits of State Employees
Section 7 - Information Furnished Commission by Employees
Section 9 - Dividends, Refunds, Rate Credits; Deposit in Special Funds; Transfer of Reserves
Section 9a - Investment Committee; Investment and Deposit of Funds by State Treasurer
Section 10 - Retirement or Termination of Employment; Effect on Policy; Conversion of Insurance
Section 10a - Additional Insurance
Section 10b - Insurance for Elderly Government Retirees and Their Dependents
Section 10c - Optional Medicare Extension
Section 10d - Disability Insurance; Withholding Payment of Premiums
Section 10e - Insurance for Commonwealth Employee Granted Leave to Care for Dependent Child
Section 11 - Death of Employee or Retired Employee; Continuation of Insurance by Spouse or Dependent
Section 11a - Divorced or Separated Spouses; Continuation of Insurance Coverage
Section 14 - Optional Insurance for Services of Health Care Organizations
Section 16 - Election to Continue Insurance Coverages; Notice
Section 17 - Dental and Vision Expenses; Reimbursement of Employees
Section 17a - Coverage for Nonprescription Enteral Formulas for Home Use
Section 17b - Hospice Services for Commonwealth Employees Insured Under Group Insurance Commission
Section 17c - Required Coverage for Prenatal Care, Childbirth, and Postpartum Care
Section 17d - Coverage for Bone Marrow Transplants
Section 17e - Scalp Hair Prostheses Necessary Due to Cancer or Leukemia Treatment
Section 17f - Newborn Hearing Screening Test; Group Insurance Commission Coverage
Section 17h - Coverage for Human Leukocyte or Histocompatibility Locus Antigen Testing
Section 17i - Prosthetic Devices and Repairs; Group Insurance Commission Coverage
Section 17j - Coverage for Children Under Age 18 for Cleft Lip and Cleft Palate
Section 17k - Coverage for Orally Administered Anticancer Medications
Section 17l - Coverage for Abuse Deterrent Opioid Drug Products
Section 17m - Preauthorization for Substance Abuse Treatment Not to Be Required
Section 17q - Pain Management Access Plan
Section 18 - Medicare Health Benefits Supplement Plan, Mandatory Transfer; Payment of Penalty
Section 19 - Release From Insurance Coverage; Payment; Reinstatement of Coverage
Section 20 - Charges or Collections of Excess Compensation
Section 21 - Health Care Services Evaluation; Vendor Quality Improvement Program; Annual Report
Section 23 - Coverage for Speech, Hearing and Language Disorders
Section 24 - State Retiree Benefits Trust Fund
Section 24a - State Retiree Benefits Trust Fund Board of Trustees; Membership; Powers and Duties
Section 25 - Insurance Coverage for Diagnosis and Treatment of Autism Spectrum Disorder
Section 28 - Coverage for Certain Services and Contraceptive Methods