215 ILCS 220/25: Notification requirements for downcoded claims.

(This Section may contain text from a Public Act with a delayed effective date)

When a claim is downcoded, the health care payor shall notify the billing health care professional using the appropriate CARCs and RARCs to clearly indicate that the claim has been downcoded and provide:

(1) the specific reason for the downcoding, including reference to the clinical information and coding guidance used to justify the downcoding;

(2) the original and revised service codes and payment amounts; and

(3) the process to initiate a dispute for a downcoding decision.