Section 1413 - Data matching and claims for reimbursement(a) All entities providing health insurance or health care coverage to individuals residing within this Commonwealth shall provide such information on coverage and benefits, as the department may specify, for any recipient of medical assistance or child support services identified by the department by name and either policy number or Social Security number. The information the department may specify in its request may include information needed to determine during what period individuals or their spouses or their dependents may be or may have been covered by the entity and the nature of the coverage that is or was provided by the entity, including the name, address and identifying number of the plan.(b) All entities providing health insurance or health care coverage to individuals residing within this Commonwealth shall accept the department's right of recovery and the assignment to the department of any right of an individual or any other entity to payment for an item or service for which payment has been made by the medical assistance program and shall receive, process and pay claims for reimbursement submitted by the department or its authorized contractor with respect to medical assistance recipients who have coverage for such claims.(b.1) The following apply: (1) All entities providing health insurance or health care coverage that require prior authorization for an item or service furnished to an individual who is also a medical assistance recipient shall accept the authorization from the medical assistance program that the item or service is covered under the medical assistance program for the recipient as if the authorization was the entity's prior authorization for the item or service.(2) This subsection does not apply to the original Medicare fee-for-service program under Parts A and B of Title XVIII of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1395 et seq.), a Medicare advantage plan offered by a Medicare advantage organization under Part C of Title XVIII of the Social Security Act, a reasonable cost reimbursement contract under 42 U.S.C. § 1395MM (relating to payments to health maintenance organizations and competitive medical plans), a health care prepayment plan under 42 U.S.C. § 1395L (relating to payment of benefits) or a prescription drug plan offered by a prescription drug plan sponsor under Part D of Title XVIII of the Social Security Act. (c) To the maximum extent permitted by Federal law and notwithstanding any policy or plan provision to the contrary, a claim by the department for reimbursement of medical assistance shall be deemed timely filed with the entity providing health insurance or health care coverage and shall not be denied solely on the basis of the date of submission of the claim, the type or format of the claim or a failure to present proper documentation at the point of sale that is the basis of the claim, if it is filed as follows: (1) within five years of the date of service for all dates of service occurring on or before June 30, 2007; or(2) within three years of the date of service for all dates of service occurring on or after July 1, 2007.(c.1) Any action by the department to enforce its rights with respect to a claim submitted by the department under this section must be commenced within six years of the department's submission of the claim. All entities providing health care coverage within this Commonwealth shall respond within forty-five days to any inquiry by the department regarding a claim for payment for any health care item or service that is submitted not later than three years after the date of provision of the health care item or service.(d) The department is authorized to enter into agreements with entities providing health insurance and health care coverage for the purpose of carrying out the provisions of this section. The agreement shall provide for the electronic exchange of data between the parties at a mutually agreed-upon frequency, but no less frequently than monthly, and may also allow for payment of a fee by the department to the entity providing health insurance or health care coverage.(e) Following notice and hearing, the department may impose a penalty of up to one thousand dollars ($1,000) per violation upon any entity that wilfully fails to comply with the obligations imposed by this section.(e.1) It is a condition of doing business in this Commonwealth that every entity subject to this section comply with the provisions of this section and agree not to deny a claim submitted by the department on the basis of a plan or contract provision that is inconsistent with subsection (b.1) or (c).(f) This section shall apply to every entity providing health insurance or health care coverage within this Commonwealth, including, but not limited to, plans, policies, contracts or certificates issued by: (1) A stock insurance company incorporated for any of the purposes set forth in section 202(c) of the act of May 17, 1921 (P.L. 682, No. 284), known as "The Insurance Company Law of 1921."(2) A mutual insurance company incorporated for any of the purposes set forth in section 202(d) of "The Insurance Company Law of 1921."(3) A professional health services plan corporation as defined in 40 Pa.C.S. Ch. 63 (relating to professional health services plan corporations).(4) A health maintenance organization as defined in the act of December 29, 1972 (P.L. 1701, No. 364), known as the "Health Maintenance Organization Act."(5) A fraternal benefit society as defined in section 2403 of "The Insurance Company Law of 1921."(6) A person who sells or issues contracts or certificates of insurance which meet the requirements of this act.(7) A hospital plan corporation as defined in 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations).(8) Health care plans subject to the Employee Retirement Income Security Act of 1974 ( Public Law 93-406, 88 Stat. 829), self-insured plans, service benefit plans, managed care organizations, pharmacy benefit managers and every other organization that is, by statute, contract or agreement, legally responsible for the payment of a claim for a health care service or item to the maximum extent permitted by Federal law.Amended by P.L. (number not assigned at time of publication) 2024 No. 115,§ 3, eff. 10/29/2024.1967, June 13, P.L. 31, art. 14, § 1413, added 2005, July 7, P.L. 177, No. 42, § 9, imd. effective. Amended 2008, July 4, P.L. 557, No. 44, §11, effective in 60 days [ 9/2/2008].