Claim for which prior authorization was given; denial; resubmission of claim

Sec. 12. (a) This section applies to a claim for a health care service rendered by a health care provider: (1) for which: (A) prior authorization is requested after June 30, 2025; and (B) a utilization review entity gives prior authorization; and (2) that is rendered in accordance with the authorization. (b) The utilization review entity shall not deny the claim described in subsection (a) unless: (1) the health care provider knowingly and materially misrepresented the health care service in the prior authorization request with the specific intent to deceive and obtain an unlawful payment from the utilization review entity; (2) the health care service was no longer a covered benefit on the date the health care service was provided; (3) the health care provider was no longer contracted with the patient's health plan on the date the health care service was provided; (4) the health care provider failed to meet the utilization review entity's timely filing requirements; (5) the utilization review entity does not have liability for the claim; or (6) the patient was not covered under the health plan on the date on which the health care service was rendered. (c) If: (1) the claim described in subsection (a) contains an unintentional and inaccurate inconsistency with the request for prior authorization; and (2) the inconsistency results in denial of the claim; the health care provider may resubmit the claim with accurate, corrected information.