If a healthcare insurer exercises recoupment, then the healthcare insurer shall provide the healthcare provider written documentation that specifies the:

1. (1) Amount of the recoupment;
2. (2) Covered person's name to which the recoupment applies;
3. (3) Patient identification number;
4. (4) Date or dates of service;
5. (5) Service or services on which the recoupment is based;
6. (6) Pending claims being recouped or future claims that will be recouped; and

7. (7)

   1. (A) Specific reason for the recoupment.
   2. (B) Recoupment based upon medical necessity determinations, level of service determinations, coding errors, or billing irregularities must be reconciled to specific claims and provide specific reasons for recoupment.

   3. (C) “Specific reasons” shall not consist of mere conclusionary statements such as “not medically necessary” but instead shall contain specific information from which the provider can:

      1. (i) Determine the basis for the recoupment; and
      2. (ii) Make a reasoned determination about whether to challenge the recoupment.
   4. (D) If a healthcare insurer recoups based on a determination that the provider billed the wrong level of care, it shall state which level of care the insurer has determined would have been appropriate.