Notice requirement

Sec. 11. If a claim is downcoded, the insurer shall: (1) notify the provider using the appropriate CARC and RARC to clearly indicate that the claim has been downcoded; and (2) provide: (A) the specific reason for the downcoding, including reference to the clinical criteria used to justify the downcoding; (B) the original and revised service codes and payment amounts; and (C) a notice of the right to appeal as described in section 12 of this chapter. As added by P.L.88-2026, SEC.6.