TRANSPARENCY IN DOWNCODING ACT

Summary

The Transparency in Downcoding Act bans health insurers from using automated tools or diagnosis codes alone to lower claim payments. It forces insurers to have a qualified physician review any downcoding, to notify providers of the change, and to offer a clear dispute process. The law applies to most group health plans and Medicaid managed‑care contracts, but not to self‑insured ERISA plans or workers‑comp coverage.

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