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40 Pa.C.S. § 3804

Exceptions to retroactive denial of reimbursement

The provisions of section 3803 (relating to retroactive denial of reimbursement) do not apply if an insurer retroactively denies reimbursement to a health care provider because any of the following apply:

(1) The information submitted to the insurer constitutes fraud, waste or abuse as defined in this chapter.

(2) The claim submitted to the insurer was a duplicate claim.

(3) Denial was required by a Federal or State government plan.

(4) Services were subject to coordination of benefits with another insurer, the medical assistance program or the Medicare program.

Official source: Pennsylvania General Assembly. Reproduced from public-domain Pennsylvania statutes; confirm against the official source for the current text. Not legal advice.