TRANSPARENCY IN DOWNCODING ACT

Summary

If enacted, this bill would prohibit health care payors from using automated processes to downcode medical claims without human review, require downcoding decisions to be made or reviewed by a natural person following AMA CPT guidelines, and prohibit downcoding based solely on diagnosis codes or in a discriminatory manner against providers treating complex conditions. It would apply to certain health insurance policies issued, amended, delivered, or renewed on or after January 1, 2028, and would also require managed care organizations under the Illinois Public Aid Code to comply.