2013 -- S 0618 | |
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LC01776 | |
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STATE OF RHODE ISLAND | |
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IN GENERAL ASSEMBLY | |
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JANUARY SESSION, A.D. 2013 | |
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____________ | |
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A N A C T | |
RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES | |
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Introduced By: Senators Goldin, Miller, Satchell, Cool Rumsey, and Sosnowski | |
Date Introduced: March 06, 2013 | |
Referred To: Senate Health & Human Services | |
It is enacted by the General Assembly as follows: | |
1-1 |
SECTION 1. Section 27-18-61 of the General Laws in Chapter 27-18 entitled "Accident |
1-2 |
and Sickness Insurance Policies" is hereby amended to read as follows: |
1-3 |
27-18-61. Prompt processing of claims. -- (a) A health care entity or health plan |
1-4 |
operating in the state shall pay all complete claims for covered health care services submitted to |
1-5 |
the health care entity or health plan by a health care provider or by a policyholder within forty |
1-6 |
(40) calendar days following the date of receipt of a complete written claim or within thirty (30) |
1-7 |
calendar days following the date of receipt of a complete electronic claim. Each health plan shall |
1-8 |
establish a written standard defining what constitutes a complete claim and shall distribute this |
1-9 |
standard to all participating providers. |
1-10 |
(b) If the health care entity or health plan denies or pends a claim, the health care entity |
1-11 |
or health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing |
1-12 |
the health care provider or policyholder of any and all reasons for denying or pending the claim |
1-13 |
and what, if any, additional information is required to process the claim. No health care entity or |
1-14 |
health plan may limit the time period in which additional information may be submitted to |
1-15 |
complete a claim. |
1-16 |
(c) Any claim that is resubmitted by a health care provider or policyholder shall be |
1-17 |
treated by the health care entity or health plan pursuant to the provisions of subsection (a) of this |
1-18 |
section. |
1-19 |
(d) A health care entity or health plan which fails to reimburse the health care provider |
1-20 |
or policyholder after receipt by the health care entity or health plan of a complete claim within the |
2-1 |
required timeframes shall pay to the health care provider or the policyholder who submitted the |
2-2 |
claim, in addition to any reimbursement for health care services provided, interest which shall |
2-3 |
accrue at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day |
2-4 |
after receipt of a complete electronic claim or on the forty-first (41st) day after receipt of a |
2-5 |
complete written claim, and ending on the date the payment is issued to the health care provider |
2-6 |
or the policyholder. |
2-7 |
(e)(1) A healthcare entity or health plan shall not deny payment for a claim for medically |
2-8 |
necessary inpatient services resulting from an emergency admission provided by a hospital solely |
2-9 |
on the basis that the hospital did not timely notify such healthcare entity or health plan that the |
2-10 |
services had been provided. |
2-11 |
(2) Nothing in this subsection shall preclude a hospital and a healthcare entity or health |
2-12 |
plan from agreeing to requirements for timely notification that medically necessary inpatient |
2-13 |
services resulting from an emergency admission have been provided and to a reduction in |
2-14 |
payment for failure to timely notify; provided, however that: (i) Any requirement for timely |
2-15 |
notification must provide for a reasonable extension of timeframes for notification for emergency |
2-16 |
services provided on weekends, state, or federal holidays, or during declared state or federally |
2-17 |
declared states of emergency; (ii) Any agreed to reduction in payment for failure to timely notify |
2-18 |
shall not exceed the lesser of two thousand dollars ($2,000) or twelve percent (12%) of the |
2-19 |
payment amount otherwise due for the services provided, and (iii) Any agreed to reduction in |
2-20 |
payment for failure to timely notify shall not be imposed if the patient's insurance coverage could |
2-21 |
not be determined by the hospital after reasonable efforts at the time the inpatient services were |
2-22 |
provided. |
2-23 |
(f) Except where the parties have developed a mutually agreed upon process for the |
2-24 |
reconciliation of coding disputes that includes a review of submitted medical records to ascertain |
2-25 |
the correct coding for payment, a hospital shall, upon receipt of payment of a claim for which |
2-26 |
payment has been adjusted based on a particular coding to a patient including the assignment of |
2-27 |
diagnosis and procedure, have the opportunity to submit the affected claim with medical records |
2-28 |
supporting the hospital's initial coding of the claim within thirty (30) days of receipt of payment. |
2-29 |
Upon receipt of such medical records, the healthcare entity or health plan shall review such |
2-30 |
information to ascertain the correct coding for payment and process the claim in accordance with |
2-31 |
the time frames set forth in subsection (a) of this section. In the event the healthcare entity or |
2-32 |
health plan processes the claim consistent with its initial determination, such decision shall be |
2-33 |
accompanied by a detailed statement in plain language of the healthcare entity or health plan |
2-34 |
setting forth the specific reasons why the initial adjustment was appropriate. A healthcare entity |
3-1 |
or health plan that increases the payment based on the information submitted by the hospital, but |
3-2 |
fails to do so in accordance with the timeframes set forth in subsection (a) of this section, shall |
3-3 |
pay to the hospital interest on the amount of such increase at the rate set pursuant to subsection |
3-4 |
(d) of this section. Neither the initial or subsequent processing of the claim by the healthcare |
3-5 |
entity or health plan shall be deemed an adverse determination if based solely on a coding |
3-6 |
determination. Nothing in this subsection shall apply to those instances in which the insurer or |
3-7 |
organization, or corporation has a reasonable suspicion of fraud or abuse. |
3-8 |
|
3-9 |
(1) No health care entity or health plan operating in the state shall be in violation of this |
3-10 |
section for a claim submitted by a health care provider or policyholder if: |
3-11 |
(i) Failure to comply is caused by a directive from a court or federal or state agency; |
3-12 |
(ii) The health care entity or health plan is in liquidation or rehabilitation or is operating |
3-13 |
in compliance with a court-ordered plan of rehabilitation; or |
3-14 |
(iii) The health care entity or health plan's compliance is rendered impossible due to |
3-15 |
matters beyond its control that are not caused by it. |
3-16 |
(2) No health care entity or health plan operating in the state shall be in violation of this |
3-17 |
section for any claim: (i) initially submitted more than ninety (90) days after the service is |
3-18 |
rendered, or (ii) resubmitted more than ninety (90) days after the date the health care provider |
3-19 |
received the notice provided for in subsection (b) of this section; provided, this exception shall |
3-20 |
not apply in the event compliance is rendered impossible due to matters beyond the control of the |
3-21 |
health care provider and were not caused by the health care provider. |
3-22 |
(3) No health care entity or health plan operating in the state shall be in violation of this |
3-23 |
section while the claim is pending due to a fraud investigation by a state or federal agency. |
3-24 |
(4) No health care entity or health plan operating in the state shall be obligated under this |
3-25 |
section to pay interest to any health care provider or policyholder for any claim if the director of |
3-26 |
business regulation finds that the entity or plan is in substantial compliance with this section. A |
3-27 |
health care entity or health plan seeking such a finding from the director shall submit any |
3-28 |
documentation that the director shall require. A health care entity or health plan which is found to |
3-29 |
be in substantial compliance with this section shall thereafter submit any documentation that the |
3-30 |
director may require on an annual basis for the director to assess ongoing compliance with this |
3-31 |
section. |
3-32 |
(5) A health care entity or health plan may petition the director for a waiver of the |
3-33 |
provision of this section for a period not to exceed ninety (90) days in the event the health care |
3-34 |
entity or health plan is converting or substantially modifying its claims processing systems. |
4-1 |
|
4-2 |
(1) "Claim" means: (i) a bill or invoice for covered services; (ii) a line item of service; or |
4-3 |
(iii) all services for one patient or subscriber within a bill or invoice. |
4-4 |
(2) "Date of receipt" means the date the health care entity or health plan receives the |
4-5 |
claim whether via electronic submission or as a paper claim. |
4-6 |
(3) "Health care entity" means a licensed insurance company or nonprofit hospital or |
4-7 |
medical or dental service corporation or plan or health maintenance organization, or a contractor |
4-8 |
as described in section 23-17.13-2(2), which operates a health plan. |
4-9 |
(4) "Health care provider" means an individual clinician, either in practice independently |
4-10 |
or in a group, who provides health care services, and |
4-11 |
|
4-12 |
substance abuse treatment facility, physician, or other licensed practitioners identified to the |
4-13 |
review agent as having primary responsibility for the care, treatment, and services rendered to a |
4-14 |
patient. |
4-15 |
(5) "Health care services" include, but are not limited to, medical, mental health, |
4-16 |
substance abuse, dental and any other services covered under the terms of the specific health plan. |
4-17 |
(6) "Health plan" means a plan operated by a health care entity that provides for the |
4-18 |
delivery of health care services to persons enrolled in those plans through: |
4-19 |
(i) Arrangements with selected providers to furnish health care services; and/or |
4-20 |
(ii) Financial incentive for persons enrolled in the plan to use the participating providers |
4-21 |
and procedures provided for by the health plan. |
4-22 |
(7) "Medically necessary" means services or supplies that are needed for the diagnosis or |
4-23 |
treatment of a medical condition and meet generally accepted standards of medical practice. For |
4-24 |
these purposes, "generally accepted standards of medical practice" means standards and |
4-25 |
guidelines that include, but are not limited to, InterQual and other supporting information based |
4-26 |
on credible scientific evidence published in peer-reviewed medical literature generally recognized |
4-27 |
by the relevant medical community, physician specialty society recommendations and the views |
4-28 |
of physicians practicing in relevant clinical areas, and any other relevant factors. |
4-29 |
|
4-30 |
designated by that person. |
4-31 |
|
4-32 |
processing and paying ninety-five percent (95%) or more of all claims within the time frame |
4-33 |
provided for in subsections (a) and (b) of this section. |
5-34 |
|
5-35 |
health care provider which is inconsistent with this section shall be void and of no force and |
5-36 |
effect. |
5-37 |
SECTION 2. Section 27-19-52 of the General Laws in Chapter 27-19 entitled "Nonprofit |
5-38 |
Hospital Service Corporations" is hereby amended to read as follows: |
5-39 |
27-19-52. Prompt processing of claims. -- (a) A health care entity or health plan |
5-40 |
operating in the state shall pay all complete claims for covered health care services submitted to |
5-41 |
the health care entity or health plan by a health care provider or by a policyholder within forty |
5-42 |
(40) calendar days following the date of receipt of a complete written claim or within thirty (30) |
5-43 |
calendar days following the date of receipt of a complete electronic claim. Each health plan shall |
5-44 |
establish a written standard defining what constitutes a complete claim and shall distribute this |
5-45 |
standard to all participating providers. |
5-46 |
(b) If the health care entity or health plan denies or pends a claim, the health care entity |
5-47 |
or health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing |
5-48 |
the health care provider or policyholder of any and all reasons for denying or pending the claim |
5-49 |
and what, if any, additional information is required to process the claim. No health care entity or |
5-50 |
health plan may limit the time period in which additional information may be submitted to |
5-51 |
complete a claim. |
5-52 |
(c) Any claim that is resubmitted by a health care provider or policyholder shall be |
5-53 |
treated by the health care entity or health plan pursuant to the provisions of subsection (a) of this |
5-54 |
section. |
5-55 |
(d) A health care entity or health plan which fails to reimburse the health care provider |
5-56 |
or policyholder after receipt by the health care entity or health plan of a complete claim within the |
5-57 |
required timeframes shall pay to the health care provider or the policyholder who submitted the |
5-58 |
claim, in addition to any reimbursement for health care services provided, interest which shall |
5-59 |
accrue at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day |
5-60 |
after receipt of a complete electronic claim or on the forty-first (41st) day after receipt of a |
5-61 |
complete written claim, and ending on the date the payment is issued to the health care provider |
5-62 |
or the policyholder. |
5-63 |
(e)(1) A healthcare entity or health plan shall not deny payment for a claim for medically |
5-64 |
necessary inpatient services resulting from an emergency admission provided by a hospital solely |
5-65 |
on the basis that the hospital did not timely notify such healthcare entity or health plan that the |
5-66 |
services had been provided. |
5-67 |
(2) Nothing in this subsection shall preclude a hospital and a healthcare entity or health |
5-68 |
plan from agreeing to requirements for timely notification that medically necessary inpatient |
6-1 |
services resulting from an emergency admission have been provided and to a reduction in |
6-2 |
payment for failure to timely notify; provided, however that: (i) Any requirement for timely |
6-3 |
notification must provide for a reasonable extension of timeframes for notification for emergency |
6-4 |
services provided on weekends, state, or federal holidays, or during declared state or federally |
6-5 |
declared states of emergency; (ii) Any agreed to reduction in payment for failure to timely notify |
6-6 |
shall not exceed the lesser of two thousand dollars ($2,000) or twelve percent (12%) of the |
6-7 |
payment amount otherwise due for the services provided, and (iii) Any agreed to reduction in |
6-8 |
payment for failure to timely notify shall not be imposed if the patient's insurance coverage could |
6-9 |
not be determined by the hospital after reasonable efforts at the time the inpatient services were |
6-10 |
provided. |
6-11 |
(f) Except where the parties have developed a mutually agreed upon process for the |
6-12 |
reconciliation of coding disputes that includes a review of submitted medical records to ascertain |
6-13 |
the correct coding for payment, a hospital shall, upon receipt of payment of a claim for which |
6-14 |
payment has been adjusted based on a particular coding to a patient including the assignment of |
6-15 |
diagnosis and procedure, have the opportunity to submit the affected claim with medical records |
6-16 |
supporting the hospital's initial coding of the claim within thirty (30) days of receipt of payment. |
6-17 |
Upon receipt of such medical records, the healthcare entity or health plan shall review such |
6-18 |
information to ascertain the correct coding for payment and process the claim in accordance with |
6-19 |
the time frames set forth in subsection (a) of this section. In the event the healthcare entity or |
6-20 |
health plan processes the claim consistent with its initial determination, such decision shall be |
6-21 |
accompanied by a detailed statement in plain language of the healthcare entity or health plan |
6-22 |
setting forth the specific reasons why the initial adjustment was appropriate. A healthcare entity |
6-23 |
or health plan that increases the payment based on the information submitted by the hospital, but |
6-24 |
fails to do so in accordance with the timeframes set forth in subsection (a) of this section, shall |
6-25 |
pay to the hospital interest on the amount of such increase at the rate set pursuant to subsection |
6-26 |
(d) of this section. Neither the initial or subsequent processing of the claim by the healthcare |
6-27 |
entity or health plan shall be deemed an adverse determination if based solely on a coding |
6-28 |
determination. Nothing in this subsection shall apply to those instances in which the insurer or |
6-29 |
organization, or corporation has a reasonable suspicion of fraud or abuse. |
6-30 |
|
6-31 |
(1) No health care entity or health plan operating in the state shall be in violation of this |
6-32 |
section for a claim submitted by a health care provider or policyholder if: |
6-33 |
(i) Failure to comply is caused by a directive from a court or federal or state agency; |
7-34 |
(ii) The health care provider or health plan is in liquidation or rehabilitation or is |
7-35 |
operating in compliance with a court-ordered plan of rehabilitation; or |
7-36 |
(iii) The health care entity or health plan's compliance is rendered impossible due to |
7-37 |
matters beyond its control that are not caused by it. |
7-38 |
(2) No health care entity or health plan operating in the state shall be in violation of this |
7-39 |
section for any claim: (i) initially submitted more than ninety (90) days after the service is |
7-40 |
rendered, or (ii) resubmitted more than ninety (90) days after the date the health care provider |
7-41 |
received the notice provided for in section 27-18-61(b); provided, this exception shall not apply |
7-42 |
in the event compliance is rendered impossible due to matters beyond the control of the health |
7-43 |
care provider and were not caused by the health care provider. |
7-44 |
(3) No health care entity or health plan operating in the state shall be in violation of this |
7-45 |
section while the claim is pending due to a fraud investigation by a state or federal agency. |
7-46 |
(4) No health care entity or health plan operating in the state shall be obligated under this |
7-47 |
section to pay interest to any health care provider or policyholder for any claim if the director of |
7-48 |
the department of business regulation finds that the entity or plan is in substantial compliance |
7-49 |
with this section. A health care entity or health plan seeking such a finding from the director shall |
7-50 |
submit any documentation that the director shall require. A health care entity or health plan which |
7-51 |
is found to be in substantial compliance with this section shall after this submit any |
7-52 |
documentation that the director may require on an annual basis for the director to assess ongoing |
7-53 |
compliance with this section. |
7-54 |
(5) A health care entity or health plan may petition the director for a waiver of the |
7-55 |
provision of this section for a period not to exceed ninety (90) days in the event the health care |
7-56 |
entity or health plan is converting or substantially modifying its claims processing systems. |
7-57 |
|
7-58 |
(1) "Claim" means: |
7-59 |
(i) A bill or invoice for covered services; |
7-60 |
(ii) A line item of service; or |
7-61 |
(iii) All services for one patient or subscriber within a bill or invoice. |
7-62 |
(2) "Date of receipt" means the date the health care entity or health plan receives the |
7-63 |
claim whether via electronic submission or has a paper claim. |
7-64 |
(3) "Health care entity" means a licensed insurance company or nonprofit hospital or |
7-65 |
medical or dental service corporation or plan or health maintenance organization, or a contractor |
7-66 |
as described in section 23-17.13-2(2), that operates a health plan. |
7-67 |
(4) "Health care provider" means an individual clinician, either in practice independently |
7-68 |
or in a group, who provides health care services, and |
8-1 |
any healthcare facility, as defined in section 23-17-2 including any mental health and/or |
8-2 |
substance abuse treatment facility, physician, or other licensed practitioners identified to the |
8-3 |
review agent as having primary responsibility for the care, treatment, and services rendered to a |
8-4 |
patient. |
8-5 |
(5) "Health care services" include, but are not limited to, medical, mental health, |
8-6 |
substance abuse, dental and any other services covered under the terms of the specific health plan. |
8-7 |
(6) "Health plan" means a plan operated by a health care entity that provides for the |
8-8 |
delivery of health care services to persons enrolled in those plans through: |
8-9 |
(i) Arrangements with selected providers to furnish health care services; and/or |
8-10 |
(ii) Financial incentive for persons enrolled in the plan to use the participating providers |
8-11 |
and procedures provided for by the health plan. |
8-12 |
(7) "Medically necessary" means services or supplies that are needed for the diagnosis or |
8-13 |
treatment of a medical condition and meet generally accepted standards of medical practice. For |
8-14 |
these purposes, "generally accepted standards of medical practice" means standards and |
8-15 |
guidelines that include, but are not limited to, InterQual and other supporting information based |
8-16 |
on credible scientific evidence published in peer-reviewed medical literature generally recognized |
8-17 |
by the relevant medical community, physician specialty society recommendations and the views |
8-18 |
of physicians practicing in relevant clinical areas, and any other relevant factors. |
8-19 |
|
8-20 |
designated by that person. |
8-21 |
|
8-22 |
processing and paying ninety-five percent (95%) or more of all claims within the time frame |
8-23 |
provided for in section 27-18-61(a) and (b). |
8-24 |
|
8-25 |
health care provider which is inconsistent with this section shall be void and of no force and |
8-26 |
effect. |
8-27 |
SECTION 3. Section 27-20-47 of the General Laws in Chapter 27-20 entitled "Nonprofit |
8-28 |
Medical Service Corporations" is hereby amended to read as follows: |
8-29 |
27-20-47. Prompt processing of claims. -- (a) A health care entity or health plan |
8-30 |
operating in the state shall pay all complete claims for covered health care services submitted to |
8-31 |
the health care entity or health plan by a health care provider or by a policyholder within forty |
8-32 |
(40) calendar days following the date of receipt of a complete written claim or within thirty (30) |
8-33 |
calendar days following the date of receipt of a complete electronic claim. Each health plan shall |
8-34 |
establish a written standard defining what constitutes a complete claim and shall distribute the |
9-1 |
standard to all participating providers. |
9-2 |
(b) If the health care entity or health plan denies or pends a claim, the health care entity |
9-3 |
or health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing |
9-4 |
the health care provider or policyholder of any and all reasons for denying or pending the claim |
9-5 |
and what, if any, additional information is required to process the claim. No health care entity or |
9-6 |
health plan may limit the time period in which additional information may be submitted to |
9-7 |
complete a claim. |
9-8 |
(c) Any claim that is resubmitted by a health care provider or policyholder shall be |
9-9 |
treated by the health care entity or health plan pursuant to the provisions of subsection (a) of this |
9-10 |
section. |
9-11 |
(d) A health care entity or health plan which fails to reimburse the health care provider |
9-12 |
or policyholder after receipt by the health care entity or health plan of a complete claim within the |
9-13 |
required timeframes shall pay to the health care provider or the policyholder who submitted the |
9-14 |
claim, in addition to any reimbursement for health care services provided, interest which shall |
9-15 |
accrue at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day |
9-16 |
after receipt of a complete electronic claim or on the forty-first (41st) day after receipt of a |
9-17 |
complete written claim, and ending on the date the payment is issued to the health care provider |
9-18 |
or the policyholder. |
9-19 |
(e)(1) A healthcare entity or health plan shall not deny payment for a claim for medically |
9-20 |
necessary inpatient services resulting from an emergency admission provided by a hospital solely |
9-21 |
on the basis that the hospital did not timely notify such healthcare entity or health plan that the |
9-22 |
services had been provided. |
9-23 |
(2) Nothing in this subsection shall preclude a hospital and a healthcare entity or health |
9-24 |
plan from agreeing to requirements for timely notification that medically necessary inpatient |
9-25 |
services resulting from an emergency admission have been provided and to a reduction in |
9-26 |
payment for failure to timely notify; provided, however that: (i) Any requirement for timely |
9-27 |
notification must provide for a reasonable extension of timeframes for notification for emergency |
9-28 |
services provided on weekends, state, or federal holidays, or during declared state or federally |
9-29 |
declared states of emergency; (ii) Any agreed to reduction in payment for failure to timely notify |
9-30 |
shall not exceed the lesser of two thousand dollars ($2,000) or twelve percent (12%) of the |
9-31 |
payment amount otherwise due for the services provided, and (iii) Any agreed to reduction in |
9-32 |
payment for failure to timely notify shall not be imposed if the patient's insurance coverage could |
9-33 |
not be determined by the hospital after reasonable efforts at the time the inpatient services were |
9-34 |
provided. |
10-1 |
(f) Except where the parties have developed a mutually agreed upon process for the |
10-2 |
reconciliation of coding disputes that includes a review of submitted medical records to ascertain |
10-3 |
the correct coding for payment, a hospital shall, upon receipt of payment of a claim for which |
10-4 |
payment has been adjusted based on a particular coding to a patient including the assignment of |
10-5 |
diagnosis and procedure, have the opportunity to submit the affected claim with medical records |
10-6 |
supporting the hospital's initial coding of the claim within thirty (30) days of receipt of payment. |
10-7 |
Upon receipt of such medical records, the healthcare entity or health plan shall review such |
10-8 |
information to ascertain the correct coding for payment and process the claim in accordance with |
10-9 |
the time frames set forth in subsection (a) of this section. In the event the healthcare entity or |
10-10 |
health plan processes the claim consistent with its initial determination, such decision shall be |
10-11 |
accompanied by a detailed statement in plain language of the healthcare entity or health plan |
10-12 |
setting forth the specific reasons why the initial adjustment was appropriate. A healthcare entity |
10-13 |
or health plan that increases the payment based on the information submitted by the hospital, but |
10-14 |
fails to do so in accordance with the timeframes set forth in subsection (a) of this section, shall |
10-15 |
pay to the hospital interest on the amount of such increase at the rate set pursuant to subsection |
10-16 |
(d) of this section. Neither the initial or subsequent processing of the claim by the healthcare |
10-17 |
entity or health plan shall be deemed an adverse determination if based solely on a coding |
10-18 |
determination. Nothing in this subsection shall apply to those instances in which the insurer or |
10-19 |
organization, or corporation has a reasonable suspicion of fraud or abuse. |
10-20 |
|
10-21 |
(1) No health care entity or health plan operating in the state shall be in violation of this |
10-22 |
section for a claim submitted by a health care provider or policyholder if: |
10-23 |
(i) Failure to comply is caused by a directive from a court or federal or state agency; |
10-24 |
(ii) The health care entity or health plan is in liquidation or rehabilitation or is operating |
10-25 |
in compliance with a court-ordered plan of rehabilitation; or |
10-26 |
(iii) The health care entity or health plan's compliance is rendered impossible due to |
10-27 |
matters beyond its control that are not caused by it. |
10-28 |
(2) No health care entity or health plan operating in the state shall be in violation of this |
10-29 |
section for any claim: (i) initially submitted more than ninety (90) days after the service is |
10-30 |
rendered, or (ii) resubmitted more than ninety (90) days after the date the health care provider |
10-31 |
received the notice provided for in section 27-18-61(b); provided, this exception shall not apply |
10-32 |
in the event compliance is rendered impossible due to matters beyond the control of the health |
10-33 |
care provider and were not caused by the health care provider. |
11-34 |
(3) No health care entity or health plan operating in the state shall be in violation of this |
11-35 |
section while the claim is pending due to a fraud investigation by a state or federal agency. |
11-36 |
(4) No health care entity or health plan operating in the state shall be obligated under this |
11-37 |
section to pay interest to any health care provider or policyholder for any claim if the director of |
11-38 |
the department of business regulation finds that the entity or plan is in substantial compliance |
11-39 |
with this section. A health care entity or health plan seeking such a finding from the director shall |
11-40 |
submit any documentation that the director shall require. A health care entity or health plan which |
11-41 |
is found to be in substantial compliance with this section shall after this submit any |
11-42 |
documentation that the director may require on an annual basis for the director to assess ongoing |
11-43 |
compliance with this section. |
11-44 |
(5) A health care entity or health plan may petition the director for a waiver of the |
11-45 |
provision of this section for a period not to exceed ninety (90) days in the event the health care |
11-46 |
entity or health plan is converting or substantially modifying its claims processing systems. |
11-47 |
|
11-48 |
(1) "Claim" means: (i) a bill or invoice for covered services; (ii) a line item of service; or |
11-49 |
(iii) all services for one patient or subscriber within a bill or invoice. |
11-50 |
(2) "Date of receipt" means the date the health care entity or health plan receives the |
11-51 |
claim whether via electronic submission or has a paper claim. |
11-52 |
(3) "Health care entity" means a licensed insurance company or nonprofit hospital or |
11-53 |
medical or dental service corporation or plan or health maintenance organization, or a contractor |
11-54 |
as described in section 23-17.13-2(2), that operates a health plan. |
11-55 |
(4) "Health care provider" means an individual clinician, either in practice independently |
11-56 |
or in a group, who provides health care services, and |
11-57 |
any healthcare facility, as defined in section 23-17-2 including any mental health and/or |
11-58 |
substance abuse treatment facility, physician, or other licensed practitioners identified to the |
11-59 |
review agent as having primary responsibility for the care, treatment, and services rendered to a |
11-60 |
patient. |
11-61 |
(5) "Health care services" include, but are not limited to, medical, mental health, |
11-62 |
substance abuse, dental and any other services covered under the terms of the specific health plan. |
11-63 |
(6) "Health plan" means a plan operated by a health care entity that provides for the |
11-64 |
delivery of health care services to persons enrolled in the plan through: |
11-65 |
(i) Arrangements with selected providers to furnish health care services; and/or |
11-66 |
(ii) Financial incentive for persons enrolled in the plan to use the participating providers |
11-67 |
and procedures provided for by the health plan. |
12-68 |
(7) "Medically necessary" means services or supplies that are needed for the diagnosis or |
12-69 |
treatment of a medical condition and meet generally accepted standards of medical practice. For |
12-70 |
these purposes, "generally accepted standards of medical practice" means standards and |
12-71 |
guidelines that include, but are not limited to, InterQual and other supporting information based |
12-72 |
on credible scientific evidence published in peer-reviewed medical literature generally recognized |
12-73 |
by the relevant medical community, physician specialty society recommendations and the views |
12-74 |
of physicians practicing in relevant clinical areas, and any other relevant factors. |
12-75 |
|
12-76 |
designated by that person. |
12-77 |
|
12-78 |
processing and paying ninety-five percent (95%) or more of all claims within the time frame |
12-79 |
provided for in section 27-18-61(a) and (b). |
12-80 |
|
12-81 |
health care provider which is inconsistent with this section shall be void and of no force and |
12-82 |
effect. |
12-83 |
SECTION 4. Section 27-41-64 of the General Laws in Chapter 27-41 entitled "Health |
12-84 |
Maintenance Organizations" is hereby amended to read as follows: |
12-85 |
27-41-64. Prompt processing of claims. -- (a) A health care entity or health plan |
12-86 |
operating in the state shall pay all complete claims for covered health care services submitted to |
12-87 |
the health care entity or health plan by a health care provider or by a policyholder within forty |
12-88 |
(40) calendar days following the date of receipt of a complete written claim or within thirty (30) |
12-89 |
calendar days following the date of receipt of a complete electronic claim. Each health plan shall |
12-90 |
establish a written standard defining what constitutes a complete claim and shall distribute this |
12-91 |
standard to all participating providers. |
12-92 |
(b) If the health care entity or health plan denies or pends a claim, the health care entity |
12-93 |
or health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing |
12-94 |
the health care provider or policyholder of any and all reasons for denying or pending the claim |
12-95 |
and what, if any, additional information is required to process the claim. No health care entity or |
12-96 |
health plan may limit the time period in which additional information may be submitted to |
12-97 |
complete a claim. |
12-98 |
(c) Any claim that is resubmitted by a health care provider or policyholder shall be |
12-99 |
treated by the health care entity or health plan pursuant to the provisions of subsection (a) of this |
12-100 |
section. |
12-101 |
(d) A health care entity or health plan which fails to reimburse the health care provider |
12-102 |
or policyholder after receipt by the health care entity or health plan of a complete claim within the |
13-1 |
required timeframes shall pay to the health care provider or the policyholder who submitted the |
13-2 |
claim, in addition to any reimbursement for health care services provided, interest which shall |
13-3 |
accrue at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day |
13-4 |
after receipt of a complete electronic claim or on the forty-first (41st) day after receipt of a |
13-5 |
complete written claim, and ending on the date the payment is issued to the health care provider |
13-6 |
or the policyholder. |
13-7 |
(e) (1) A healthcare entity or health plan shall not deny payment for a claim for |
13-8 |
medically necessary inpatient services resulting from an emergency admission provided by a |
13-9 |
hospital solely on the basis that the hospital did not timely notify such healthcare entity or health |
13-10 |
plan that the services had been provided. |
13-11 |
(2) Nothing in this subsection shall preclude a hospital and a healthcare entity or health |
13-12 |
plan from agreeing to requirements for timely notification that medically necessary inpatient |
13-13 |
services resulting from an emergency admission have been provided and to a reduction in |
13-14 |
payment for failure to timely notify; provided, however that: (i) Any requirement for timely |
13-15 |
notification must provide for a reasonable extension of timeframes for notification for emergency |
13-16 |
services provided on weekends, state, or federal holidays, or during declared state or federally |
13-17 |
declared states of emergency; (ii) Any agreed to reduction in payment for failure to timely notify |
13-18 |
shall not exceed the lesser of two thousand dollars ($2,000) or twelve percent (12%) of the |
13-19 |
payment amount otherwise due for the services provided, and (iii) Any agreed to reduction in |
13-20 |
payment for failure to timely notify shall not be imposed if the patient's insurance coverage could |
13-21 |
not be determined by the hospital after reasonable efforts at the time the inpatient services were |
13-22 |
provided. |
13-23 |
(f) Except where the parties have developed a mutually agreed upon process for the |
13-24 |
reconciliation of coding disputes that includes a review of submitted medical records to ascertain |
13-25 |
the correct coding for payment, a hospital shall, upon receipt of payment of a claim for which |
13-26 |
payment has been adjusted based on a particular coding to a patient including the assignment of |
13-27 |
diagnosis and procedure, have the opportunity to submit the affected claim with medical records |
13-28 |
supporting the hospital's initial coding of the claim within thirty (30) days of receipt of payment. |
13-29 |
Upon receipt of such medical records, the healthcare entity or health plan shall review such |
13-30 |
information to ascertain the correct coding for payment and process the claim in accordance with |
13-31 |
the time frames set forth in subsection (a) of this section. In the event the healthcare entity or |
13-32 |
health plan processes the claim consistent with its initial determination, such decision shall be |
13-33 |
accompanied by a detailed statement in plain language of the healthcare entity or health plan |
13-34 |
setting forth the specific reasons why the initial adjustment was appropriate. A healthcare entity |
14-1 |
or health plan that increases the payment based on the information submitted by the hospital, but |
14-2 |
fails to do so in accordance with the timeframes set forth in subsection (a) of this section, shall |
14-3 |
pay to the hospital interest on the amount of such increase at the rate set pursuant to subsection |
14-4 |
(d) of this section. Neither the initial or subsequent processing of the claim by the healthcare |
14-5 |
entity or health plan shall be deemed an adverse determination if based solely on a coding |
14-6 |
determination. Nothing in this subsection shall apply to those instances in which the insurer or |
14-7 |
organization, or corporation has a reasonable suspicion of fraud or abuse. |
14-8 |
|
14-9 |
(1) No health care entity or health plan operating in the state shall be in violation of this |
14-10 |
section for a claim submitted by a health care provider or policyholder if: |
14-11 |
(i) Failure to comply is caused by a directive from a court or federal or state agency; |
14-12 |
(ii) The health care entity or health plan is in liquidation or rehabilitation or is operating |
14-13 |
in compliance with a court-ordered plan of rehabilitation; or |
14-14 |
(iii) The health care entity or health plan's compliance is rendered impossible due to |
14-15 |
matters beyond its control, which are not caused by it. |
14-16 |
(2) No health care entity or health plan operating in the state shall be in violation of this |
14-17 |
section for any claim: (i) initially submitted more than ninety (90) days after the service is |
14-18 |
rendered, or (ii) resubmitted more than ninety (90) days after the date the health care provider |
14-19 |
received the notice provided for in section 27-18-61(b); provided, this exception shall not apply |
14-20 |
in the event compliance is rendered impossible due to matters beyond the control of the health |
14-21 |
care provider and were not caused by the health care provider. |
14-22 |
(3) No health care entity or health plan operating in the state shall be in violation of this |
14-23 |
section while the claim is pending due to a fraud investigation by a state or federal agency. |
14-24 |
(4) No health care entity or health plan operating in the state shall be obligated under this |
14-25 |
section to pay interest to any health care provider or policyholder for any claim if the director of |
14-26 |
the department of business regulation finds that the entity or plan is in substantial compliance |
14-27 |
with this section. A health care entity or health plan seeking that finding from the director shall |
14-28 |
submit any documentation that the director shall require. A health care entity or health plan which |
14-29 |
is found to be in substantial compliance with this section shall submit any documentation the |
14-30 |
director may require on an annual basis for the director to assess ongoing compliance with this |
14-31 |
section. |
14-32 |
(5) A health care entity or health plan may petition the director for a waiver of the |
14-33 |
provision of this section for a period not to exceed ninety (90) days in the event the health care |
14-34 |
entity or health plan is converting or substantially modifying its claims processing systems. |
15-1 |
|
15-2 |
(1) "Claim" means: (i) a bill or invoice for covered services; (ii) a line item of service; or |
15-3 |
(iii) all services for one patient or subscriber within a bill or invoice. |
15-4 |
(2) "Date of receipt" means the date the health care entity or health plan receives the |
15-5 |
claim whether via electronic submission or as a paper claim. |
15-6 |
(3) "Health care entity" means a licensed insurance company or nonprofit hospital or |
15-7 |
medical or dental service corporation or plan or health maintenance organization, or a contractor |
15-8 |
as described in section 23-17.13-2(2) that operates a health plan. |
15-9 |
(4) "Health care provider" means an individual clinician, either in practice independently |
15-10 |
or in a group, who provides health care services, and is |
15-11 |
any healthcare facility, as defined in section 23-17-2 including any mental health and/or |
15-12 |
substance abuse treatment facility, physician, or other licensed practitioners identified to the |
15-13 |
review agent as having primary responsibility for the care, treatment, and services rendered to a |
15-14 |
patient. |
15-15 |
(5) "Health care services" include, but are not limited to, medical, mental health, |
15-16 |
substance abuse, dental and any other services covered under the terms of the specific health plan. |
15-17 |
(6) "Health plan" means a plan operated by a health care entity that provides for the |
15-18 |
delivery of health care services to persons enrolled in the plan through: |
15-19 |
(i) Arrangements with selected providers to furnish health care services; and/or |
15-20 |
(ii) Financial incentive for persons enrolled in the plan to use the participating providers |
15-21 |
and procedures provided for by the health plan. |
15-22 |
(7) ) "Medically necessary" means services or supplies that are needed for the diagnosis |
15-23 |
or treatment of a medical condition and meet generally accepted standards of medical practice. |
15-24 |
For these purposes, "generally accepted standards of medical practice" means standards and |
15-25 |
guidelines that include, but are not limited to, InterQual and other supporting information based |
15-26 |
on credible scientific evidence published in peer-reviewed medical literature generally recognized |
15-27 |
by the relevant medical community, physician specialty society recommendations and the views |
15-28 |
of physicians practicing in relevant clinical areas, and any other relevant factors. |
15-29 |
|
15-30 |
designated by that person. |
15-31 |
|
15-32 |
processing and paying ninety-five percent (95%) or more of all claims within the time frame |
15-33 |
provided for in section 27-18-61(a) and (b). |
16-34 |
|
16-35 |
health care provider which is inconsistent with this section shall be void and of no force and |
16-36 |
effect. |
16-37 |
SECTION 5. This act shall take effect upon passage. |
| |
======= | |
LC01776 | |
======== | |
EXPLANATION | |
BY THE LEGISLATIVE COUNCIL | |
OF | |
A N A C T | |
RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES | |
*** | |
17-1 |
This act would revise the processing of health insurance claims relating to timely |
17-2 |
notification, coding disputes, mental health and/or substance abuse treatment as well as defining |
17-3 |
medically necessary services. |
17-4 |
This act would take effect upon passage. |
| |
======= | |
LC01776 | |
======= |