New Hampshire Insurance Department Issues Guidance on Retroactive Denial of Health Claims

CONCORD, NH (March 4, 2025) – The New Hampshire Insurance Department (NHID) has issued a bulletin clarifying the limitations on health carriers’ ability to retroactively deny health claims and recoup reimbursements from healthcare providers. The guidance addresses improper retroactive denials beyond the legally permitted 12-month period and reinforces the statutory requirements that govern these practices.

Under RSA 420-J:8-b, health carriers may only retroactively deny claims if they meet two key conditions: they must provide a written explanation to the healthcare provider, and the denial must occur within 12 months of the original payment date. The statute further requires that carriers issue advance written notice at least 15 days prior to initiating any recoupments. This notice must include sufficient detail to allow providers to understand the rationale behind the denial and make necessary corrections. Generalized statements such as “an adjustment has been made” do not meet the statutory standard.

Additionally, when issuing retroactive denials, carriers must include the appropriate federal Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) to explain the reason for the claim denial and adjustment. In the case of pharmacy claims, carriers must also reference the National Council for Prescription Drug Programs (NCPDP) denial reason codes.

The bulletin also clarifies that retroactive denials beyond the 12-month period are only allowed in limited circumstances. Specifically, carriers cannot retroactively deny claims for covered services solely due to the discovery of another payer’s potential liability. Carriers must accurately determine the primary payer before issuing claim payments, and they are prohibited from recouping payments from providers in coordination of benefits scenarios. Furthermore, any retroactive adjustment must be limited strictly to the portion of a claim for which another payer is responsible, in accordance with applicable coordination of benefits regulations.

“The New Hampshire Insurance Department is committed to ensuring that healthcare providers and insurers operate within the statutory framework designed by the legislature to protect fairness and stability in the claims process,” said Insurance Commissioner DJ Bettencourt. “This guidance reinforces the obligations of health carriers and safeguards providers from undue financial burdens caused by improper retroactive claim denials.”

“These updates not only clarify statutory requirements but also help ensure consistency in how claims are processed and adjudicated,” said Deputy Insurance Commissioner Keith Nyhan. “By establishing clear expectations, we aim to enhance transparency and consumer protections for Granite Staters.”

The full bulletin, Docket #INS 25-21-AB, can be viewed at https://mm.nh.gov/files/uploads/nhid/documents/ins-25-021-ab-retroactive-denial-health-claims.pdf.

The New Hampshire Insurance Department Can Help

The New Hampshire Insurance Department’s mission is to promote and protect the public good by ensuring the existence of a safe and competitive insurance marketplace through the development and enforcement of the insurance laws of the State of New Hampshire. Contact us with any questions or concerns you may have regarding your insurance coverage at 800-852-3416 or 603-271‐2261, or by email at consumerservices@ins.nh.gov. For more information, visit https://insurance.nh.gov/.