Ama Policy

Physicians’ Experiences with Retrospective Denial of Payment and Down-Coding by Managed Care Plans H-320.948

Retroactive Denial

It is the policy of our AMA, when a health plan or utilization review organization makes a determination to retrospectively deny payment for a medical service, or down-code such a service, the physician rendering the service, as well as the patient who received the service, shall receive written notification in a timely manner that includes: (1) the principal reason(s) for the determination; (2) the clinical rationale used in making the determination; and (3) a statement describing the process for appeal.

Policy Timeline

CMS Rep. 5, I-00 Reaffirmation I-01 Reaffirmation I-04 Reaffirmation A-08 Reaffirmed in lieu of: Res. 242, A-17 Reaffirmed: CMS Rep. 08, A-17 Reaffirmation: I-17 Reaffirmation: A-18 Reaffirmation: A-19 Reaffirmed: CMS Rep. 4, A-21