SB 3114

Summary

As enrolled: - Prohibits home rule units from regulating downcoding of medical claims in policies issued, amended, delivered, or renewed on or after January 1, 2028. - Prohibits a health care payor from implementing any policy or using any algorithm or other automated process, system, or tool that bypasses the evaluation of all information included by the billing health care professional to downcode a claim. - Allows a health care payor to use an automated process to identify claims that may justify a downcoding determination. - Requires all downcoding determinations to be made or reviewed by a natural person following American Medical Association Current Procedural Terminology coding guidelines in effect at the time. - Prohibits a health care payor from downcoding a claim based solely on the reported diagnosis codes. - Sets provisions concerning notification requirements and the dispute process for downcoded claims. - Prohibits a health care payor from using downcoding practices in a targeted or discriminatory manner against health care professionals who routinely treat patients with complex or chronic conditions. - Requires all managed care organizations shall comply with the requirements of the Transparency in Downcoding Act. Effective January 1, 2028. - Exempts employee or employer self-insured health benefit plans under the federal Employee Retirement Income Security Act of 1974 and health care provided pursuant to the Workers' Compensation Act or the Workers' Occupational Diseases Act.

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