Prohibition on altering CPT code for claim; exceptions

Sec. 6.5. (a) An insurer may not alter the CPT code submitted for a clean claim or pay for a CPT code of lesser monetary value unless: (1) the CPT code submitted is not in accordance with correct coding guidelines and rules, clinical care guidelines, or the terms and conditions of the participating provider's agreement or contract with the insurer; or (2) the medical record of the clean claim has been reviewed by an employee or contractor of the insurer. (b) An insurer may not alter a clean claim to only pay for the CPT codes necessary for an individual's final diagnosis, if the CPT codes billed were deemed medically necessary according to generally accepted clinical care guidelines to reach the final diagnosis. (c) This section does not prohibit a provider from appealing a claim.