HB1292 — Changes to Existing Law | SD Legislature Tracker

NEW SECTION added to Chapter 58-17

H: Except as otherwise provided in this section, a previously paid claim may be recouped, recovered, or retroactively denied by the health carrier within eighteen months year from the date the claim payment was made, if the health carrier has provided written notice of the reason to the provider. This does not apply to a previously paid claim that: (1) Was submitted fraudulently; (2) Is the subject of an adjustment with a different health carrier, administrator, or payor, and the adjustment is not affected by a contractual relationship, association, or affiliation involving claims payment, processing, or pricing; (3) Was for medical services covered by casualty insurance, as defined by §§ 58-9-11 to 58-9-27, inclusive; (4) Was for medical services covered by a self-insured health plan governed by the Employee Retirement Income Security Act of 1974 (ERISA), U.S.C. §§ 1001 to 1461, inclusive (July 6, 2012); (5) Was for medical services covered under medicare, 42 U.S.C. §§ 1395-1395lll, inclusive (March 15, 2025), medicaid, 42 U.S.C. §§ 1396 to 1396w-6, inclusive (July 4, 2025), or any other federal law; (6) Was for medical services covered by workers' compensation, as provided for in title 62; or (7) Was incorrect because the provider or the member was already paid for the medical services identified in the claim. A violation of this section is subject to enforcement by the Division of Insurance under title 58. For purposes of this section, "retroactively deny a previously paid claim" means to retroactively collect claim payments made to a provider by requiring repayment of the payments, reducing other payments currently owed to the provider, withholding or setting off against future payments, or reducing or affecting the future claim payments to the provider in any other manner. 5