=======

art.005/5/005/4/005/3/005/2/005/1

=======

     ARTICLE 5 AS AMENDED

RELATING TO GOVERNMENT REORGANIZATION

     SECTION 1. Chapter 23-17.12 of the General Laws entitled "Health Care Services -

Utilization Review Act" is hereby repealed in its entirety.

CHAPTER 23-17.12

Health Care Services - Utilization Review Act

     23-17.12-1. Purpose of chapter.

     The purpose of the chapter is to:

     (1) Promote the delivery of quality health care in a cost effective manner;

     (2) Foster greater coordination between health care providers, patients, payors and

utilization review entities;

     (3) Protect patients, businesses, and providers by ensuring that review agents are qualified

to perform utilization review activities and to make informed decisions on the appropriateness of

medical care; and

     (4) Ensure that review agents maintain the confidentiality of medical records in accordance

with applicable state and federal laws.

     23-17.12-2. Definitions.

     As used in this chapter, the following terms are defined as follows:

     (1) "Adverse determination" means a utilization review decision by a review agent not to

authorize a health care service. A decision by a review agent to authorize a health care service in

an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute

an adverse determination if the review agent and provider are in agreement regarding the decision.

Adverse determinations include decisions not to authorize formulary and nonformulary medication.

     (2) "Appeal" means a subsequent review of an adverse determination upon request by a

patient or provider to reconsider all or part of the original decision.

     (3) "Authorization" means the review agent's utilization review, performed according to

subsection 23-17.12-2(20), concluded that the allocation of health care services of a provider, given

or proposed to be given to a patient was approved or authorized.

     (4) "Benefit determination" means a decision of the enrollee's entitlement to payment for

covered health care services as defined in an agreement with the payor or its delegate.

     (5) "Certificate" means a certificate of registration granted by the director to a review agent.

     (6) "Complaint" means a written expression of dissatisfaction by a patient, or provider. The

appeal of an adverse determination is not considered a complaint.

     (7) "Concurrent assessment" means an assessment of the medical necessity and/or

appropriateness of health care services conducted during a patient's hospital stay or course of

treatment. If the medical problem is ongoing, this assessment may include the review of services

after they have been rendered and billed. This review does not mean the elective requests for

clarification of coverage or claims review or a provider's internal quality assurance program except

if it is associated with a health care financing mechanism.

     (8) "Department" means the department of health.

     (9) "Director" means the director of the department of health.

     (10) "Emergent health care services" has the same meaning as that meaning contained in

the rules and regulations promulgated pursuant to chapter 12.3 of title 42 as may be amended from

time to time and includes those resources provided in the event of the sudden onset of a medical,

mental health, or substance abuse or other health care condition manifesting itself by acute

symptoms of a severity (e.g. severe pain) where the absence of immediate medical attention could

reasonably be expected to result in placing the patient's health in serious jeopardy, serious

impairment to bodily or mental functions, or serious dysfunction of any body organ or part.

     (11) "Patient" means an enrollee or participant in all hospital or medical plans seeking

health care services and treatment from a provider.

     (12) "Payor" means a health insurer, self-insured plan, nonprofit health service plan, health

insurance service organization, preferred provider organization, health maintenance organization

or other entity authorized to offer health insurance policies or contracts or pay for the delivery of

health care services or treatment in this state.

     (13) "Practitioner" means any person licensed to provide or otherwise lawfully providing

health care services, including, but not limited to, a physician, dentist, nurse, optometrist, podiatrist,

physical therapist, clinical social worker, or psychologist.

     (14) "Prospective assessment" means an assessment of the medical necessity and/or

appropriateness of health care services prior to services being rendered.

     (15) "Provider" means any health care facility, as defined in § 23-17-2 including any mental

health and/or substance abuse treatment facility, physician, or other licensed practitioners identified

to the review agent as having primary responsibility for the care, treatment, and services rendered

to a patient.

     (16) "Retrospective assessment" means an assessment of the medical necessity and/or

appropriateness of health care services that have been rendered. This shall not include reviews

conducted when the review agency has been obtaining ongoing information.

     (17) "Review agent" means a person or entity or insurer performing utilization review that

is either employed by, affiliated with, under contract with, or acting on behalf of:

     (i) A business entity doing business in this state;

     (ii) A party that provides or administers health care benefits to citizens of this state,

including a health insurer, self-insured plan, non-profit health service plan, health insurance service

organization, preferred provider organization or health maintenance organization authorized to

offer health insurance policies or contracts or pay for the delivery of health care services or

treatment in this state; or

     (iii) A provider.

     (18) "Same or similar specialty" means a practitioner who has the appropriate training and

experience that is the same or similar as the attending provider in addition to experience in treating

the same problems to include any potential complications as those under review.

     (19) "Urgent health care services" has the same meaning as that meaning contained in the

rules and regulations promulgated pursuant to chapter 12.3 of title 42 as may be amended from

time to time and includes those resources necessary to treat a symptomatic medical, mental health,

or substance abuse or other health care condition requiring treatment within a twenty-four (24) hour

period of the onset of such a condition in order that the patient's health status not decline as a

consequence. This does not include those conditions considered to be emergent health care services

as defined in subdivision (10).

     (20) "Utilization review" means the prospective, concurrent, or retrospective assessment

of the necessity and/or appropriateness of the allocation of health care services of a provider, given

or proposed to be given to a patient. Utilization review does not include:

     (i) Elective requests for the clarification of coverage; or

     (ii) Benefit determination; or

     (iii) Claims review that does not include the assessment of the medical necessity and

appropriateness; or

     (iv) A provider's internal quality assurance program except if it is associated with a health

care financing mechanism; or

     (v) The therapeutic interchange of drugs or devices by a pharmacy operating as part of a

licensed inpatient health care facility; or

     (vi) The assessment by a pharmacist licensed pursuant to the provisions of chapter 19 of

title 5 and practicing in a pharmacy operating as part of a licensed inpatient health care facility in

the interpretation, evaluation and implementation of medical orders, including assessments and/or

comparisons involving formularies and medical orders.

     (21) "Utilization review plan" means a description of the standards governing utilization

review activities performed by a private review agent.

     (22) "Health care services" means and includes an admission, diagnostic procedure,

therapeutic procedure, treatment, extension of stay, the ordering and/or filling of formulary or

nonformulary medications, and any other services, activities, or supplies that are covered by the

patient's benefit plan.

     (23) "Therapeutic interchange" means the interchange or substitution of a drug with a

dissimilar chemical structure within the same therapeutic or pharmacological class that can be

expected to have similar outcomes and similar adverse reaction profiles when given in equivalent

doses, in accordance with protocols approved by the president of the medical staff or medical

director and the director of pharmacy.

     23-17.12-3. General certificate requirements.

     (a) A review agent shall not conduct utilization review in the state unless the department

has granted the review agent a certificate.

     (b) Individuals shall not be required to hold separate certification under this chapter when

acting as either an employee of, an affiliate of, a contractor for, or otherwise acting on behalf of a

certified review agent.

     (c) The department shall issue a certificate to an applicant that has met the minimum

standards established by this chapter, and regulations promulgated in accordance with it, including

the payment of any fees as required, and other applicable regulations of the department.

     (d) A certificate issued under this chapter is not transferable, and the transfer of fifty percent

(50%) or more of the ownership of a review agent shall be deemed a transfer.

     (e) After consultation with the payors and providers of health care, the department shall

adopt regulations necessary to implement the provisions of this chapter.

     (f) The director of health is authorized to establish any fees for initial application, renewal

applications, and any other administrative actions deemed necessary by the director to implement

this chapter.

     (g) The total cost of certification under this title shall be borne by the certified entities and

shall be one hundred and fifty percent (150%) of the total salaries paid to the certifying personnel

of the department engaged in those certifications less any salary reimbursements and shall be paid

to the director to and for the use of the department. That assessment shall be in addition to any taxes

and fees otherwise payable to the state.

     (h) The application and other fees required under this chapter shall be sufficient to pay for

the administrative costs of the certificate program and any other reasonable costs associated with

carrying out the provisions of this chapter.

     (i) A certificate expires on the second anniversary of its effective date unless the certificate

is renewed for a two (2) year term as provided in this chapter.

     (j) Any systemic changes in the review agents operations relative to certification

information on file shall be submitted to the department for approval within thirty (30) days prior

to implementation.

     23-17.12-4. Application process.

     (a) An applicant requesting certification or recertification shall:

     (1) Submit an application provided by the director; and

     (2) Pay the application fee established by the director through regulation and § 23-17.12-

3(f).

     (b) The application shall:

     (1) Be on a form and accompanied by supporting documentation that the director requires;

and

     (2) Be signed and verified by the applicant.

     (c) Before the certificate expires, a certificate may be renewed for an additional two (2)

years.

     (d) If a completed application for recertification is being processed by the department, a

certificate may be continued until a renewal determination is made.

     (e) In conjunction with the application, the review agent shall submit information that the

director requires including:

     (1) A request that the state agency regard specific portions of the standards and criteria or

the entire document to constitute "trade secrets" within the meaning of that term in § 38-2-

2(4)(i)(B);

     (2) The policies and procedures to ensure that all applicable state and federal laws to protect

the confidentiality of individual medical records are followed;

     (3) A copy of the materials used to inform enrollees of the requirements under the health

benefit plan for seeking utilization review or pre-certification and their rights under this chapter,

including information on appealing adverse determinations;

     (4) A copy of the materials designed to inform applicable patients and providers of the

requirements of the utilization review plan;

     (5) A list of the third party payors and business entities for which the review agent is

performing utilization review in this state and a brief description of the services it is providing for

each client; and

     (6) Evidence of liability insurance or of assets sufficient to cover potential liability.

     (f) The information provided must demonstrate that the review agent will comply with the

regulations adopted by the director under this chapter.

     23-17.12-5. General application requirements.

     An application for certification or recertification shall be accompanied by documentation

to evidence the following:

     (1) The requirement that the review agent provide patients and providers with a summary

of its utilization review plan including a summary of the standards, procedures and methods to be

used in evaluating proposed or delivered health care services;

     (2) The circumstances, if any, under which utilization review may be delegated to any other

utilization review program and evidence that the delegated agency is a certified utilization review

agency delegated to perform utilization review pursuant to all of the requirements of this chapter;

     (3) A complaint resolution process consistent with subsection 23-17.12-2(6) and

acceptable to the department, whereby patients, their physicians, or other health care providers may

seek resolution of complaints and other matters of which the review agent has received written

notice;

     (4) The type and qualifications of personnel (employed or under contract) authorized to

perform utilization review, including a requirement that only a practitioner with the same license

status as the ordering practitioner, or a licensed physician or dentist, is permitted to make a

prospective or concurrent adverse determination;

     (5) The requirement that a representative of the review agent is reasonably accessible to

patients, patient's family and providers at least five (5) days a week during normal business in

Rhode Island and during the hours of the agency's review operations;

     (6) The policies and procedures to ensure that all applicable state and federal laws to protect

the confidentiality of individual medical records are followed;

     (7) The policies and procedures regarding the notification and conduct of patient interviews

by the review agent;

     (8) The requirement that no employee of, or other individual rendering an adverse

determination for, a review agent may receive any financial incentives based upon the number of

denials of certification made by that employee or individual;

     (9) The requirement that the utilization review agent shall not impede the provision of

health care services for treatment and/or hospitalization or other use of a provider's services or

facilities for any patient;

     (10) Evidence that the review agent has not entered into a compensation agreement or

contract with its employees or agents whereby the compensation of its employees or its agents is

based upon a reduction of services or the charges for those services, the reduction of length of stay,

or utilization of alternative treatment settings; provided, nothing in this chapter shall prohibit

agreements and similar arrangements; and

     (11) An adverse determination and internal appeals process consistent with § 23-17.12-9

and acceptable to the department, whereby patients, their physicians, or other health care providers

may seek prompt reconsideration or appeal of adverse determinations by the review agent.

     23-17.12-6. Denial, suspension, or revocation of certificate.

     (a) The department may deny a certificate upon review of the application if, upon review

of the application, it finds that the applicant proposing to conduct utilization review does not meet

the standards required by this chapter or by any regulations promulgated pursuant to this chapter.

     (b) The department may revoke a certificate and/or impose reasonable monetary penalties

not to exceed five thousand dollars ($5,000) per violation in any case in which:

     (1) The review agent fails to comply substantially with the requirements of this chapter or

of regulations adopted pursuant to this chapter;

     (2) The review agent fails to comply with the criteria used by it in its application for a

certificate; or

     (3) The review agent refuses to permit examination by the director to determine compliance

with the requirements of this chapter and regulations promulgated pursuant to the authority granted

to the director in this chapter; provided, however, that the examination shall be subject to the

confidentiality and "need to know" provisions of subdivisions 23-17.12-9(c)(4) and (5). These

determinations may involve consideration of any written grievances filed with the department

against the review agent by patients or providers.

     (c) Any applicant or certificate holder aggrieved by an order or a decision of the department

made under this chapter without a hearing may, within thirty (30) days after notice of the order or

decision, make a written request to the department for a hearing on the order or decision pursuant

to § 42-35-15.

     (d) The procedure governing hearings authorized by this section shall be in accordance

with §§ 42-35-9 -- 42-35-13 as stipulated in § 42-35-14(a). A full and complete record shall be kept

of all proceedings, and all testimony shall be recorded but need not be transcribed unless the

decision is appealed pursuant to § 42-35-15. A copy or copies of the transcript may be obtained by

any interested party upon payment of the cost of preparing the copy or copies. Witnesses may be

subpoenaed by either party.

     23-17.12-7. Judicial review.

     Any person who has exhausted all administrative remedies available to him or her within

the department, and who is aggrieved by a final decision of the department under § 23-17.12-6, is

entitled to judicial review pursuant to §§ 42-35-15 and 42-35-16.

     23-17.12-8. Waiver of requirements.

     (a) Except for utilization review agencies performing utilization review activities to

determine the necessity and/or appropriateness of substance abuse and mental health care, treatment

or services, the department shall waive all the requirements of this chapter, with the exception of

those contained in §§ 23-17.12-9, (a)(1)-(3), (5), (6), (8), (b)(1)-(6), and (c)(2)-(6), 23-17.12-12,

and 23-17.12-14, for a review agent that has received, maintains and provides evidence to the

department of accreditation from the utilization review accreditation commission (URAC) or other

organization approved by the director. The waiver shall be applicable only to those services that

are included under the accreditation by the utilization review accreditation commission or other

approved organization.

     (b) The department shall waive the requirements of this chapter only when a direct conflict

exists with those activities of a review agent that are conducted pursuant to contracts with the state

or the federal government or those activities under other state or federal jurisdictions.

     (c) The limitation in subsection 23-17.12-8(b) notwithstanding, the department may waive

or exempt all or part of the requirements of this chapter by mutual written agreement with a state

department or agency when such waiver or exemption is determined to be necessary and

appropriate to the administration of a health care related program. The department shall promulgate

such regulations as deemed appropriate to implement this provision.

     23-17.12-8.1. Variance of statutory requirements..

     (a) The department is authorized to issue a statutory variance from one or more of the

specific requirements of this chapter to a review agent where it determines that such variance is

necessary to permit the review agent to evaluate and address practitioner billing and practice

patterns when the review agent believes in good faith that such patterns evidence the existence of

fraud or abuse. Any variance issued by the department pursuant to this section shall be limited in

application to those services billed directly by the practitioner. Prior to issuing a statutory variance

the department shall provide notice and a public hearing to ensure necessary patient and health care

provider protections in the process. Statutory variances shall be issued for a period not to exceed

one year and may be subject to such terms and conditions deemed necessary by the department.

     (b) On or before January 15th of each year, the department shall issue a report to the general

assembly summarizing any review agent activity as a result of a waiver granted under the provisions

of this section.

     23-17.12-9. Review agency requirement for adverse determination and internal

appeals.

     (a) The adverse determination and appeals process of the review agent shall conform to the

following:

     (1) Notification of a prospective adverse determination by the review agent shall be mailed

or otherwise communicated to the provider of record and to the patient or other appropriate

individual as follows:

     (i) Within fifteen (15) business days of receipt of all the information necessary to complete

a review of non-urgent and/or non-emergent services;

     (ii) Within seventy-two (72) hours of receipt of all the information necessary to complete

a review of urgent and/or emergent services; and

     (iii) Prior to the expected date of service.

     (2) Notification of a concurrent adverse determination shall be mailed or otherwise

communicated to the patient and to the provider of record period as follows:

     (i) To the provider(s) prior to the end of the current certified period; and

     (ii) To the patient within one business day of making the adverse determination.

     (3) Notification of a retrospective adverse determination shall be mailed or otherwise

communicated to the patient and to the provider of record within thirty (30) business days of receipt

of a request for payment with all supporting documentation for the covered benefit being reviewed.

     (4) A utilization review agency shall not retrospectively deny authorization for health care

services provided to a covered person when an authorization has been obtained for that service

from the review agent unless the approval was based upon inaccurate information material to the

review or the health care services were not provided consistent with the provider's submitted plan

of care and/or any restrictions included in the prior approval granted by the review agent.

     (5) Any notice of an adverse determination shall include:

     (i) The principal reasons for the adverse determination, to include explicit documentation

of the criteria not met and/or the clinical rationale utilized by the agency's clinical reviewer in

making the adverse determination. The criteria shall be in accordance with the agency criteria noted

in subsection 23-17.12-9(d) and shall be made available within the first level appeal timeframe if

requested unless otherwise provided as part of the adverse determination notification process;

     (ii) The procedures to initiate an appeal of the adverse determination, including the name

and telephone number of the person to contract with regard to an appeal;

     (iii) The necessary contact information to complete the two-way direct communication

defined in subdivision 23-17.12-9(a)(7); and

     (iv) The information noted in subdivision 23-27.12-9(a)(5)(i)(ii)(iii) for all verbal

notifications followed by written notification to the patient and provider(s).

     (6) All initial retrospective adverse determinations of a health care service that had been

ordered by a physician, dentist or other practitioner shall be made, documented and signed

consistent with the regulatory requirements which shall be developed by the department with the

input of review agents, providers and other affected parties.

     (7) A level one appeal decision of an adverse determination shall not be made until an

appropriately qualified and licensed review physician, dentist or other practitioner has spoken to,

or otherwise provided for, an equivalent two-way direct communication with the patient's attending

physician, dentist, other practitioner, other designated or qualified professional or provider

responsible for treatment of the patient concerning the medical care, with the exception of the

following:

     (i) When the attending provider is not reasonably available;

     (ii) When the attending provider chooses not to speak with agency staff;

     (iii) When the attending provider has negotiated an agreement with the review agent for

alternative care; and/or

     (iv) When the attending provider requests a peer to peer communication prior to the adverse

determination, the review agency shall then comply with subdivision 23-17.12-9(c)(1) in

responding to such a request. Such requests shall be on the case specific basis unless otherwise

arranged for in advance by the provider.

     (8) All initial, prospective and concurrent adverse determinations of a health care service

that had been ordered by a physician, dentist or other practitioner shall be made, documented and

signed by a licensed practitioner with the same licensure status as the ordering practitioner or a

licensed physician or dentist. This does not prohibit appropriately qualified review agency staff

from engaging in discussions with the attending provider, the attending provider's designee or

appropriate health care facility and office personnel regarding alternative service and treatment

options. Such a discussion shall not constitute an adverse determination provided though that any

change to the provider's original order and/or any decision for an alternative level of care must be

made and/or appropriately consented to by the attending provider or the provider's designee

responsible for treating the patient.

     (9) The requirement that, upon written request made by or on behalf of a patient, any

adverse determination and/or appeal shall include the written evaluation and findings of the

reviewing physician, dentist or other practitioner. The review agent is required to accept a verbal

request made by or on behalf of a patient for any information where a provider or patient can

demonstrate that a timely response is urgent.

     (b) The review agent shall conform to the following for the appeal of an adverse

determination:

     (1) The review agent shall maintain and make available a written description of the appeal

procedure by which either the patient or the provider of record may seek review of determinations

not to authorize a health care service. The process established by each review agent may include a

reasonable period within which an appeal must be filed to be considered and that period shall not

be less than sixty (60) days.

     (2) The review agent shall notify, in writing, the patient and provider of record of its

decision on the appeal as soon as practical, but in no case later than fifteen (15) or twenty-one (21)

business days if verbal notice is given within fifteen (15) business days after receiving the required

documentation on the appeal.

     (3) The review agent shall also provide for an expedited appeals process for emergency or

life threatening situations. Each review agent shall complete the adjudication of expedited appeals

within two (2) business days of the date the appeal is filed and all information necessary to complete

the appeal is received by the review agent.

     (4) All first level appeals of determinations not to authorize a health care service that had

been ordered by a physician, dentist, or other practitioner shall be made, documented, and signed

by a licensed practitioner with the same licensure status as the ordering practitioner or a licensed

physician or a licensed dentist.

     (5) All second level appeal decisions shall be made, signed, and documented by a licensed

practitioner in the same or a similar general specialty as typically manages the medical condition,

procedure, or treatment under discussion.

     (6) The review agent shall maintain records of written appeals and their resolution, and

shall provide reports as requested by the department.

     (c) The review agency must conform to the following requirements when making its

adverse determination and appeal decisions:

     (1) The review agent must assure that the licensed practitioner or licensed physician is

reasonably available to review the case as required under subdivision 23-17.12-9(a)(7) and shall

conform to the following:

     (i) Each agency peer reviewer shall have access to and review all necessary information as

requested by the agency and/or submitted by the provider(s) and/or patients;

     (ii) Each agency shall provide accurate peer review contact information to the provider at

the time of service, if requested, and/or prior to such service, if requested. This contact information

must provide a mechanism for direct communication with the agency's peer reviewer;

     (iii) Agency peer reviewers shall respond to the provider's request for a two-way direct

communication defined in subdivision 23-17.12-9(a)(7)(iv) as follows:

     (A) For a prospective review of non-urgent and non-emergent health care services, a

response within one business day of the request for a peer discussion;

     (B) For concurrent and prospective reviews of urgent and emergent health care services, a

response within a reasonable period of time of the request for a peer discussion; and

     (C) For retrospective reviews, prior to the first level appeal decision.

     (iv) The review agency will have met the requirements of a two-way direct communication,

when requested and/or as required prior to the first level of appeal, when it has made two (2)

reasonable attempts to contact the attending provider directly.

     (v) Repeated violations of this section shall be deemed to be substantial violations pursuant

to § 23-17.12-14 and shall be cause for the imposition of penalties under that section.

     (2) No reviewer at any level under this section shall be compensated or paid a bonus or

incentive based on making or upholding an adverse determination.

     (3) No reviewer under this section who has been involved in prior reviews of the case under

appeal or who has participated in the direct care of the patient may participate as the sole reviewer

in reviewing a case under appeal; provided, however, that when new information has been made

available at the first level of appeal, then the review may be conducted by the same reviewer who

made the initial adverse determination.

     (4) A review agent is only entitled to review information or data relevant to the utilization

review process. A review agent may not disclose or publish individual medical records or any

confidential medical information obtained in the performance of utilization review activities. A

review agent shall be considered a third party health insurer for the purposes of § 5-37.3-6(b)(6) of

this state and shall be required to maintain the security procedures mandated in § 5-37.3-4(c).

     (5) Notwithstanding any other provision of law, the review agent, the department, and all

other parties privy to information which is the subject of this chapter shall comply with all state

and federal confidentiality laws, including, but not limited to, chapter 37.3 of title 5 (Confidentiality

of Health Care Communications and Information Act) and specifically § 5-37.3-4(c), which

requires limitation on the distribution of information which is the subject of this chapter on a "need

to know" basis, and § 40.1-5-26.

     (6) The department may, in response to a complaint that is provided in written form to the

review agent, review an appeal regarding any adverse determination, and may request information

of the review agent, provider or patient regarding the status, outcome or rationale regarding the

decision.

     (d) The requirement that each review agent shall utilize and provide upon request, by

Rhode Island licensed hospitals and the Rhode Island Medical Society, in either electronic or paper

format, written medically acceptable screening criteria and review procedures which are

established and periodically evaluated and updated with appropriate consultation with Rhode Island

licensed physicians, hospitals, including practicing physicians, and other health care providers in

the same specialty as would typically treat the services subject to the criteria as follows:

     (1) Utilization review agents shall consult with no fewer than five (5) Rhode Island licensed

physicians or other health care providers. Further, in instances where the screening criteria and

review procedures are applicable to inpatients and/or outpatients of hospitals, the medical director

of each licensed hospital in Rhode Island shall also be consulted. Utilization review agents who

utilize screening criteria and review procedures provided by another entity may satisfy the

requirements of this section if the utilization review agent demonstrates to the satisfaction of the

director that the entity furnishing the screening criteria and review procedures has complied with

the requirements of this section.

     (2) Utilization review agents seeking initial certification shall conduct the consultation for

all screening and review criteria to be utilized. Utilization review agents who have been certified

for one year or longer shall be required to conduct the consultation on a periodic basis for the

utilization review agent's highest volume services subject to utilization review during the prior year;

services subject to the highest volume of adverse determinations during the prior year; and for any

additional services identified by the director.

     (3) Utilization review agents shall not include in the consultations as required under

paragraph (1) of this subdivision, any physicians or other health services providers who have

financial relationships with the utilization review agent other than financial relationships for

provisions of direct patient care to utilization review agent enrollees and reasonable compensation

for consultation as required by paragraph (1) of this subdivision.

     (4) All documentation regarding required consultations, including comments and/or

recommendations provided by the health care providers involved in the review of the screening

criteria, as well as the utilization review agent's action plan or comments on any recommendations,

shall be in writing and shall be furnished to the department on request. The documentation shall

also be provided on request to any licensed health care provider at a nominal cost that is sufficient

to cover the utilization review agent's reasonable costs of copying and mailing.

     (5) Utilization review agents may utilize non-Rhode Island licensed physicians or other

health care providers to provide the consultation as required under paragraph (1) of this subdivision,

when the utilization review agent can demonstrate to the satisfaction of the director that the related

services are not currently provided in Rhode Island or that another substantial reason requires such

approach.

     (6) Utilization review agents whose annualized data reported to the department

demonstrate that the utilization review agent will review fewer than five hundred (500) such

requests for authorization may request a variance from the requirements of this section.

     23-17.12-10. External appeal requirements.

     (a) In cases where the second level of appeal to reverse an adverse determination is

unsuccessful, the review agent shall provide for an external appeal by an unrelated and objective

appeal agency, selected by the director. The director shall promulgate rules and regulations

including, but not limited to, criteria for designation, operation, policy, oversight, and termination

of designation as an external appeal agency. The external appeal agency shall not be required to be

certified under this chapter for activities conducted pursuant to its designation.

     (b) The external appeal shall have the following characteristics:

     (1) The external appeal review and decision shall be based on the medical necessity for the

health care or service and the appropriateness of service delivery for which authorization has been

denied.

     (2) Neutral physicians, dentists, or other practitioners in the same or similar general

specialty as typically manages the health care service shall be utilized to make the external appeal

decisions.

     (3) Neutral physicians, dentists, or other practitioners shall be selected from lists:

     (i) Mutually agreed upon by the provider associations, insurers, and the purchasers of

health services; and

     (ii) Used during a twelve (12) month period as the source of names for neutral physician,

dentist, or other practitioner reviewers.

     (4) The neutral physician, dentist, or other practitioner may confer either directly with the

review agent and provider, or with physicians or dentists appointed to represent them.

     (5) Payment for the appeal fee charged by the neutral physician, dentist, or other

practitioner shall be shared equally between the two (2) parties to the appeal; provided, however,

that if the decision of the utilization review agent is overturned, the appealing party shall be

reimbursed by the utilization review agent for their share of the appeal fee paid under this

subsection.

     (6) The decision of the external appeal agency shall be binding; however, any person who

is aggrieved by a final decision of the external appeal agency is entitled to judicial review in a court

of competent jurisdiction.

     23-17.12-11. Repealed.

     23-17.12-12. Reporting requirements.

     (a) The department shall establish reporting requirements to determine if the utilization

review programs are in compliance with the provisions of this chapter and applicable regulations.

     (b) By November 14, 2014, the department shall report to the general assembly regarding

hospital admission practices and procedures and the effects of such practices and procedures on the

care and wellbeing of patients who present behavioral healthcare conditions on an emergency basis.

The report shall be developed with the cooperation of the department of behavioral healthcare,

developmental disabilities, and hospitals and of the department of children, youth, and families,

and shall recommend changes to state law and regulation to address any necessary and appropriate

revisions to the department's regulations related to utilization review based on the Federal Mental

Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Patient Protection and

Affordable Care Act, Pub. L. 111-148, and the state's regulatory interpretation of parity in insurance

coverage of behavioral healthcare. These recommended or adopted revisions to the department's

regulations shall include, but not be limited to:

     (1) Adverse determination and internal appeals, with particular regard to the time necessary

to complete a review of urgent and/or emergent services for patients with behavioral health needs;

     (2) External appeal requirements;

     (3) The process for investigating whether insurers and agents are complying with the

provisions of chapter 17.12 of title 23 in light of parity in insurance coverage for behavioral

healthcare, with particular regard to emergency admissions; and

     (4) Enforcement of the provisions of chapter 17.12 of title 23 in light of insurance parity

for behavioral healthcare.

     23-17.12-13. Lists.

     The director shall periodically provide a list of private review agents issued certificates and

the renewal date for those certificates to all licensed health care facilities and any other individual

or organization requesting the list.

     23-17.12-14. Penalties.

     A person who substantially violates any provision of this chapter or any regulation adopted

under this chapter or who submits any false information in an application required by this chapter

is guilty of a misdemeanor and on conviction is subject to a penalty not exceeding five thousand

dollars ($5,000).

     23-17.12-15. Annual report.

     The director shall issue an annual report to the governor and the general assembly

concerning the conduct of utilization review in the state. The report shall include a description of

utilization programs and the services they provide, an analysis of complaints filed against private

review agents by patients or providers and an evaluation of the impact of utilization review

programs on patient access to care.

     23-17.12-16. Fees.

     The proceeds of any fees, monetary penalties, and fines collected pursuant to the provisions

of this chapter shall be deposited as general revenues.

     23-17.12-17. Severability.

     If any provision of this chapter or the application of any provision to any person or

circumstance shall be held invalid, that invalidity shall not affect the provisions or application of

this chapter which can be given effect without the invalid provision or application, and to this end

the provisions of this chapter are declared to be severable.

     SECTION 2. Chapter 23-17.13 of the General Laws entitled "Health Care Accessibility

and Quality Assurance Act" is hereby repealed in its entirety.

CHAPTER 23-17.13

Health Care Accessibility and Quality Assurance Act

     23-17.13-1. Purpose.

     The legislature declares that:

     (1) It is in the best interest of the public that those individuals and care entities involved

with the delivery of plan coverage in our state meet the standards of this chapter to insure

accessibility and quality for the state's patients;

     (2) Nothing in the legislation is intended to prohibit a health care entity or contractor from

forming limited networks of providers; and

     (3) It is a vital state function to establish these standards for the conduct of health plans by

a health care entity in Rhode Island.

     23-17.13-2. Definitions.

     As used in this chapter:

     (1) "Adverse decision" means any decision by a review agent not to certify an admission,

service, procedure, or extension of stay. A decision by a reviewing agent to certify an admission,

service, or procedure in an alternative treatment setting, or to certify a modified extension of stay,

shall not constitute an adverse decision if the reviewing agent and the requesting provider are in

agreement regarding the decision.

     (2) "Contractor" means a person/entity that:

     (i) Establishes, operates or maintains a network of participating providers;

     (ii) Contracts with an insurance company, a hospital or medical or dental service plan, an

employer, whether under written or self insured, an employee organization, or any other entity

providing coverage for health care services to administer a plan; and/or

     (iii) Conducts or arranges for utilization review activities pursuant to chapter 17.12 of this

title.

     (3) "Direct service ratio" means the amount of premium dollars expended by the plan for

covered services provided to enrollees on a plan's fiscal year basis.

     (4) "Director" means the director of the department of health.

     (5) "Emergency services" has the same meaning as the meaning contained in the rules and

regulations promulgated pursuant to chapter 12.3 of title 42, as may be amended from time to time,

and includes the sudden onset of a medical or mental condition that the absence of immediate

medical attention could reasonably be expected to result in placing the patient's health in serious

jeopardy, serious impairment to bodily or mental functions, or serious dysfunction of any bodily

organ or part.

     (6) "Health care entity" means a licensed insurance company, hospital, or dental or medical

service plan or health maintenance organization, or a contractor as described in subdivision (2),

that operates a health plan.

     (7) "Health care services" includes, but is not limited to, medical, mental health, substance

abuse, and dental services.

     (8) "Health plan" means a plan operated by a health care entity as described in subdivision

(6) that provides for the delivery of care services to persons enrolled in the plan through:

     (i) Arrangements with selected providers to furnish health care services; and/or

     (ii) Financial incentives for persons enrolled in the plan to use the participating providers

and procedures provided for by the plan.

     (9) "Provider" means a physician, hospital, pharmacy, laboratory, dentist, or other state

licensed or other state recognized provider of health care services or supplies, and whose services

are recognized pursuant to 213(d) of the Internal Revenue Code, 26 U.S.C. § 213(d), that has

entered into an agreement with a health care entity as described in subdivision (6) or contractor as

described in subdivision (2) to provide these services or supplies to a patient enrolled in a plan.

     (10) "Provider incentive plan" means any compensation arrangement between a health care

entity or plan and a provider or provider group that may directly or indirectly have the effect of

reducing or limiting services provided with respect to an individual enrolled in a plan.

     (11) "Qualified health plan" means a plan that the director of the department of health

certified, upon application by the program, as meeting the requirements of this chapter.

     (12) "Qualified utilization review program" means utilization review program that meets

the requirements of chapter 17.12 of this title.

     (13) "Most favored rate clause" means a provision in a provider contract whereby the rates

or fees to be paid by a health plan are fixed, established or adjusted to be equal to or lower than the

rates or fees paid to the provider by any other health plan or third party payor.

     23-17.13-3. Certification of health plans.

     (a) Certification process.

     (1) Certification.

     (i) The director shall establish a process for certification of health plans meeting the

requirements of certification in subsection (b).

     (ii) The director shall act upon the health plan's completed application for certification

within ninety (90) days of receipt of such application for certification.

     (2) Review and recertification. To ensure compliance with subsection (b), the director shall

establish procedures for the periodic review and recertification of qualified health plans not less

than every five (5) years; provided, however, that the director may review the certification of a

qualified health plan at any time if there exists evidence that a qualified health plan may be in

violation of subsection (b).

     (3) Cost of certification. The total cost of obtaining and maintaining certification under this

title and compliance with the requirements of the applicable rules and regulations are borne by the

entities so certified and shall be one hundred and fifty percent (150%) of the total salaries paid to

the certifying personnel of the department engaged in those certifications less any salary

reimbursements and shall be paid to the director to and for the use of the department. That

assessment shall be in addition to any taxes and fees otherwise payable to the state.

     (4) Standard definitions. To help ensure a patient's ability to make informed decisions

regarding their health care, the director shall promulgate regulation(s) to provide for standardized

definitions (unless defined in existing statute) of the following terms in this subdivision, provided,

however, that no definition shall be construed to require a health care entity to add any benefit, to

increase the scope of any benefit, or to increase any benefit under any contract:

     (i) Allowable charge;

     (ii) Capitation;

     (iii) Co-payments;

     (iv) Co-insurance;

     (v) Credentialing;

     (vi) Formulary;

     (vii) Grace period;

     (viii) Indemnity insurance;

     (ix) In-patient care;

     (x) Maximum lifetime cap;

     (xi) Medical necessity;

     (xii) Out-of-network;

     (xiii) Out-patient;

     (xiv) Pre-existing conditions;

     (xv) Point of service;

     (xvi) Risk sharing;

     (xvii) Second opinion;

     (xviii) Provider network;

     (xix) Urgent care.

     (b) Requirements for certification. The director shall establish standards and procedures

for the certification of qualified health plans that conduct business in this state and who have

demonstrated the ability to ensure that health care services will be provided in a manner to assure

availability and accessibility, adequate personnel and facilities, and continuity of service, and has

demonstrated arrangements for ongoing quality assurance programs regarding care processes and

outcomes; other standards shall consist of, but are not limited to, the following:

     (1) Prospective and current enrollees in health plans must be provided information as to

the terms and conditions of the plan consistent with the rules and regulations promulgated under

chapter 12.3 of title 42 so that they can make informed decisions about accepting and utilizing the

health care services of the health plan. This must be standardized so that customers can compare

the attributes of the plans, and all information required by this paragraph shall be updated at

intervals determined by the director. Of those items required under this section, the director shall

also determine which items shall be routinely distributed to prospective and current enrollees as

listed in this subsection and which items may be made available upon request. The items to be

disclosed are:

     (i) Coverage provisions, benefits, and any restriction or limitations on health care services,

including but not limited to, any exclusions as follows: by category of service, and if applicable,

by specific service, by technology, procedure, medication, provider or treatment modality,

diagnosis and condition, the latter three (3) of which shall be listed by name.

     (ii) Experimental treatment modalities that are subject to change with the advent of new

technology may be listed solely by the broad category "Experimental Treatments". The information

provided to consumers shall include the plan's telephone number and address where enrollees may

call or write for more information or to register a complaint regarding the plan or coverage

provision.

     (2) Written statement of the enrollee's right to seek a second opinion, and reimbursement

if applicable.

     (3) Written disclosure regarding the appeals process described in § 23-17.12-1 et seq. and

in the rules and regulations for the utilization review of care services, promulgated by the

department of health, the telephone numbers and addresses for the plan's office which handles

complaints as well as for the office which handles the appeals process under § 23-17.12-1 et seq.

and the rules and regulations for the utilization of health.

     (4) Written statement of prospective and current enrollees' right to confidentiality of all

health care record and information in the possession and/or control of the plan, its employees, its

agents and parties with whom a contractual agreement exists to provide utilization review or who

in any way have access to care information. A summary statement of the measures taken by the

plan to ensure confidentiality of an individual's health care records shall be disclosed.

     (5) Written disclosure of the enrollee's right to be free from discrimination by the health

plan and the right to refuse treatment without jeopardizing future treatment.

     (6) Written disclosure of a plan's policy to direct enrollees to particular providers. Any

limitations on reimbursement should the enrollee refuse the referral must be disclosed.

     (7) A summary of prior authorization or other review requirements including

preauthorization review, concurrent review, post-service review, post-payment review and any

procedure that may lead the patient to be denied coverage for or not be provided a particular service.

     (8) Any health plan that operates a provider incentive plan shall not enter into any

compensation agreement with any provider of covered services or pharmaceutical manufacturer

pursuant to which specific payment is made directly or indirectly to the provider as an inducement

or incentive to reduce or limit services, to reduce the length of stay or the use of alternative

treatment settings or the use of a particular medication with respect to an individual patient,

provided however, that capitation agreements and similar risk sharing arrangements are not

prohibited.

     (9) Health plans must disclose to prospective and current enrollees the existence of

financial arrangements for capitated or other risk sharing arrangements that exist with providers in

a manner described in paragraphs (i), (ii), and (iii):

     (i) "This health plan utilizes capitated arrangements, with its participating providers, or

contains other similar risk sharing arrangements;

     (ii) This health plan may include a capitated reimbursement arrangement or other similar

risk sharing arrangement, and other financial arrangements with your provider;

     (iii) This health plan is not capitated and does not contain other risk sharing arrangements."

     (10) Written disclosure of criteria for accessing emergency health care services as well as

a statement of the plan's policies regarding payment for examinations to determine if emergency

health care services are necessary, the emergency care itself, and the necessary services following

emergency treatment or stabilization. The health plan must respond to the request of the treating

provider for post-stabilization treatment by approving or denying it as soon as possible.

     (11) Explanation of how health plan limitations impact enrollees, including information on

enrollee financial responsibility for payment for co-insurance, co-payment, or other non-covered,

out-of-pocket, or out-of-plan services. This shall include information on deductibles and benefits

limitations including, but not limited to, annual limits and maximum lifetime benefits.

     (12) The terms under which the health plan may be renewed by the plan enrollee, including

any reservation by the plan of any right to increase premiums.

     (13) Summary of criteria used to authorize treatment.

     (14) A schedule of revenues and expenses, including direct service ratios and other

statistical information which meets the requirements set forth below on a form prescribed by the

director.

     (15) Plan costs of health care services, including but not limited to all of the following:

     (i) Physician services;

     (ii) Hospital services, including both inpatients and outpatient services;

     (iii) Other professional services;

     (iv) Pharmacy services, excluding pharmaceutical products dispensed in a physician's

office;

     (v) Health education;

     (vi) Substance abuse services and mental health services.

     (16) Plan complaint, adverse decision, and prior authorization statistics. This statistical data

shall be updated annually:

     (i) The ratio of the number of complaints received to the total number of covered persons,

reported by category, listed in paragraphs (b)(15)(i) -- (vi);

     (ii) The ratio of the number of adverse decisions issued to the number of complaints

received, reported by category;

     (iii) The ratio of the number of prior authorizations denied to the number of prior

authorizations requested, reported by category;

     (iv) The ratio of the number of successful enrollee appeals to the total number of appeals

filed.

     (17) Plans must demonstrate that:

     (i) They have reasonable access to providers, so that all covered health care services will

be provided. This requirement cannot be waived and must be met in all areas where the health plan

has enrollees;

     (ii) Urgent health care services, if covered, shall be available within a time frame that meets

standards set by the director.

     (18) A comprehensive list of participating providers listed by office location, specialty if

applicable, and other information as determined by the director, updated annually.

     (19) Plans must provide to the director, at intervals determined by the director, enrollee

satisfaction measures. The director is authorized to specify reasonable requirements for these

measures consistent with industry standards to assure an acceptable degree of statistical validity

and comparability of satisfaction measures over time and among plans. The director shall publish

periodic reports for the public providing information on health plan enrollee satisfaction.

     (c) Issuance of certification.

     (1) Upon receipt of an application for certification, the director shall notify and afford the

public an opportunity to comment upon the application.

     (2) A health care plan will meet the requirements of certification, subsection (b) by

providing information required in subsection (b) to any state or federal agency in conformance with

any other applicable state or federal law, or in conformity with standards adopted by an accrediting

organization provided that the director determines that the information is substantially similar to

the previously mentioned requirements and is presented in a format that provides a meaningful

comparison between health plans.

     (3) All health plans shall be required to establish a mechanism, under which providers,

including local providers participating in the plan, provide input into the plan's health care policy,

including technology, medications and procedures, utilization review criteria and procedures,

quality and credentialing criteria, and medical management procedures.

     (4) All health plans shall be required to establish a mechanism under which local individual

subscribers to the plan provide input into the plan's procedures and processes regarding the delivery

of health care services.

     (5) A health plan shall not refuse to contract with or compensate for covered services an

otherwise eligible provider or non-participating provider solely because that provider has in good

faith communicated with one or more of his or her patients regarding the provisions, terms or

requirements of the insurer's products as they relate to the needs of that provider's patients.

     (6) (i) All health plans shall be required to publicly notify providers within the health plans'

geographic service area of the opportunity to apply for credentials. This notification process shall

be required only when the plan contemplates adding additional providers and may be specific as to

geographic area and provider specialty. Any provider not selected by the health plan may be placed

on a waiting list.

     (ii) This credentialing process shall begin upon acceptance of an application from a

provider to the plan for inclusion.

     (iii) Each application shall be reviewed by the plan's credentialing body.

     (iv) All health plans shall develop and maintain credentialing criteria to be utilized in

adding providers from the plans' network. Credentialing criteria shall be based on input from

providers credentialed in the plan and these standards shall be available to applicants. When

economic considerations are part of the decisions, the criteria must be available to applicants. Any

economic profiling must factor the specialty utilization and practice patterns and general

information comparing the applicant to his or her peers in the same specialty will be made available.

Any economic profiling of providers must be adjusted to recognize case mix, severity of illness,

age of patients and other features of a provider's practice that may account for higher than or lower

than expected costs. Profiles must be made available to those so profiled.

     (7) A health plan shall not exclude a provider of covered services from participation in its

provider network based solely on:

     (i) The provider's degree or license as applicable under state law; or

     (ii) The provider of covered services lack of affiliation with, or admitting privileges at a

hospital, if that lack of affiliation is due solely to the provider's type of license.

     (8) Health plans shall not discriminate against providers solely because the provider treats

a substantial number of patients who require expensive or uncompensated medical care.

     (9) The applicant shall be provided with all reasons used if the application is denied.

     (10) Plans shall not be allowed to include clauses in physician or other provider contracts

that allow for the plan to terminate the contract "without cause"; provided, however, cause shall

include lack of need due to economic considerations.

     (11) (i) There shall be due process for non-institutional providers for all adverse decisions

resulting in a change of privileges of a credentialed non-institutional provider. The details of the

health plan's due process shall be included in the plan's provider contracts.

     (ii) A health plan is deemed to have met the adequate notice and hearing requirement of

this section with respect to a non-institutional provider if the following conditions are met (or are

waived voluntarily by the non-institutional provider):

     (A) The provider shall be notified of the proposed actions and the reasons for the proposed

action.

     (B) The provider shall be given the opportunity to contest the proposed action.

     (C) The health plan has developed an internal appeals process that has reasonable time

limits for the resolution of an internal appeal.

     (12) If the plan places a provider or provider group at financial risk for services not

provided by the provider or provider group, the plan must require that a provider or group has met

all appropriate standards of the department of business regulation.

     (13) A health plan shall not include a most favored rate clause in a provider contract.

     23-17.13-4. Penalties and enforcement.

     (a) The director of the department of health may, in lieu of the suspension or revocation of

a license, levy an administrative penalty in an amount not less than five hundred dollars ($500) nor

more than fifty thousand dollars ($50,000), if reasonable notice, in writing, is given of the intent to

levy the penalty and the particular health organization has a reasonable time in which to remedy

the defect in its operations which gave rise to the penalty citation. The director of health may

augment this penalty by an amount equal to the sum that the director calculates to be the damages

suffered by enrollees or other members of the public.

     (b) Any person who knowingly and willfully violates this chapter shall be guilty of a

misdemeanor and may be punished by a fine not to exceed five hundred dollars ($500) or by

imprisonment for a period not exceeding one year, or both.

     (c) (1) If the director of health shall for any reason have cause to believe that any violation

of this chapter has occurred or is threatened, the director of health may give notice to the particular

health organization and to their representatives, or other persons who appear to be involved in the

suspected violation, to arrange a conference with the alleged violators or their authorized

representatives for the purpose of attempting to ascertain the facts relating to the suspected

violation, and, in the event it appears that any violation has occurred or is threatened, to arrive at

an adequate and effective means of correcting or preventing the violation;

     (2) Proceedings under this subsection shall be governed by chapter 35 of title 42.

     (d) (1) The director of health may issue an order directing a particular health organization

or a representative of that health organization to cease and desist from engaging in any act or

practice in violation of the provisions of this chapter;

     (2) Within thirty (30) days after service of the order to cease and desist, the respondent may

request a hearing on the question of whether acts or practices in violation of this chapter have

occurred. Those hearings shall be conducted pursuant to §§ 42-35-9 through 42-35-13, and judicial

review shall be available as provided by §§ 42-35-15 and 42-35-16.

     (e) In the case of any violation of the provisions of this chapter, if the director of health

elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist

order issued pursuant to subsection (d), the director of health may institute a proceeding to obtain

injunctive relief, or seeking other appropriate relief, in the superior court for the county of

Providence.

     23-17.13-5. Severability.

     If any section, clause, or provision of this chapter shall be held either unconstitutional or

ineffective in whole or in part to the extent that it is not unconstitutional or ineffective, it shall be

valid and effective and no other section, clause or provision shall on account thereof be termed

invalid or ineffective.

     23-17.13-6. Contracts with providers for dental services.

     (a) No contract between a dental plan of a health care entity and a dentist for the provision

of services to patients may require that a dentist provide services to its subscribers at a fee set by

the health care entity unless said services are covered services under the applicable subscriber

agreement. "Covered services," as used herein, means services reimbursable under the applicable

subscriber agreement, subject to such contractual limitations on subscriber benefits as may apply,

including, for example, deductibles, waiting period or frequency limitations.

     (b) For the purposes of this section "dental plan" shall include any policy of insurance

which is issued by a health care entity which provides for coverage of dental services not in

connection with a medical plan.

     23-17.13-7. Contracts with providers and optometric services.

     (a) No contract between an eye care provider and a company offering accident and sickness

insurance as defined in chapter 18 of title 27; a nonprofit medical service corporation as defined in

chapter 20 of title 27; or a health maintenance organization as defined in chapter 41 of title 27; or

a vision plan, may require that an eye care provider provide services or materials to its subscribers

at a fee set by the insurer or vision plan unless the insurer or vision plan compensates the eye care

provider for the provision of such services or materials to the patient. Reimbursement paid by the

insurer or vision plan for covered services and materials shall not provide nominal reimbursement

in order to claim that services and materials are covered services.

     (b) (1) "Services" means services and materials for which reimbursement from the vision

plan is provided for by an enrollee's plan contract, or for which a reimbursement would be available

but for the application of the enrollee's contractual limitations of deductibles, copayments, or

coinsurance.

     (2) "Materials" means and includes, but is not limited to, lenses, devices containing lenses,

prisms, lens treatments and coatings, contact lenses, orthoptics, vision training, and prosthetic

devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa.

     (3) "Eye care provider" means an optometrist, optician, or ophthalmologist.

     SECTION 3. Chapter 23-17.18 of the General Laws entitled "Health Plan Modification

Act" is hereby repealed in its entirety.

CHAPTER 23-17.18

Health Plan Modification Act

     23-17.18-1. Modification of health plans.

     (a) A health plan may materially modify the terms of a participating agreement it maintains

with a physician only if the plan disseminates in writing by mail to the physician the contents of

the proposed modification and an explanation, in nontechnical terms, of the modification's impact.

     (b) The health plan shall provide the physician an opportunity to amend or terminate the

physician contract with the health plan within sixty (60) days of receipt of the notice of

modification. Any termination of a physician contract made pursuant to this section shall be

effective fifteen (15) calendar days from the mailing of the notice of termination in writing by mail

to the health plan. The termination shall not affect the method of payment or reduce the amount of

reimbursement to the physician by the health plan for any patient in active treatment for an acute

medical condition at the time the patient's physician terminates his, her, or its physician contract

with the health plan until the active treatment is concluded or, if earlier, one year after the

termination; and, with respect to the patient, during the active treatment period the physician shall

be subject to all the terms and conditions of the terminated physician contract, including but not

limited to, all reimbursement provisions which limit the patient's liability.

     (c) Nothing in this section shall apply to accident-only, specified disease, hospital

indemnity, Medicare supplement, long-term care, disability income, or other limited benefit health

insurance policies.

     SECTION 4. Title 27 of the General Laws entitled "INSURANCE" is hereby amended by

adding thereto the following chapter:

CHAPTER 18.8

HEALTH CARE ACCESSIBILITY AND QUALITY ASSURANCE ACT

     27-18.8-1. Purpose.

     The legislature declares that:

     (1) It is in the best interest of the public that those individuals and health care entities

involved with the delivery of health plan coverage in our state meet the standards of this chapter to

ensure accessibility and quality for the state's patients; and

     (2) Nothing in this legislation is intended to prohibit a health care entity from forming

limited networks of providers; and

     (3) It is a vital state function to establish these standards for the conduct of health care

entities in Rhode Island and for public health well-being; and

     (4) Nothing in this chapter is intended to prohibit or discourage the health insurance

commissioner from consulting or collaborating with the department of health, or any other state or

federal agency, to the extent the commissioner in his or her discretion determines such consultation

and/or collaboration is necessary and/or appropriate for the administration and enforcement of this

chapter.

     27-18.8-2. Definitions.

     As used in this chapter:

     (1) "Adverse benefit determination" means a decision not to authorize a health care service,

including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole

or in part, for a benefit. A decision by a utilization review agent to authorize a health care service

in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute

an adverse determination if the review agent and provider are in agreement regarding the decision.

Adverse benefit determinations include:

     (i) "Administrative adverse benefit determinations," meaning any adverse benefit

determination that does not require the use of medical judgment or clinical criteria such as a

determination of an individual's eligibility to participate in coverage, a determination that a benefit

is not a covered benefit, or any rescission of coverage; and

     (ii) "Non-administrative adverse benefit determinations," meaning any adverse benefit

determination that requires or involves the use of medical judgement or clinical criteria to

determine whether the service reviewed is medically necessary and/or appropriate. This includes

the denial of treatments determined to be experimental or investigational, and any denial of

coverage of a prescription drug because that drug is not on the health care entity's formulary.

     (2) "Appeal" or "internal appeal" means a subsequent review of an adverse benefit

determination upon request by a claimant to include the beneficiary or provider to reconsider all or

part of the original adverse benefit determination.

     (3) "Authorized representative" means an individual acting on behalf of the beneficiary and

shall include: the ordering provider,; any individual to whom the beneficiary has given express

written consent to act on his or her behalf,; a person authorized by law to provide substituted

consent for the beneficiary; and, when the beneficiary is unable to provide consent, a family

member of the beneficiary.

     (4) "Beneficiary" means a policy holder subscriber, enrollee, or other individual

participating in a health benefit plan.

     (5) "Benefit determination" means a decision to approve or deny a request to provide or

make payment for a health care service.

     (6) "Certificate" means a certificate granted by the commissioner to a health care entity

meeting the requirements of this act chapter.

     (7) "Commissioner" means the commissioner of the office of the health insurance

commissioner.

     (8) "Complaint" means an oral or written expression of dissatisfaction by a beneficiary,

authorized representative, or provider. The appeal of an adverse benefit determination is not

considered a complaint.

     (9) "Delegate" means a person or entity authorized pursuant to a delegation of authority or

directly or re-delegation of authority, by a health care entity or network plan to perform one or

more of the functions and responsibilities of a health care entity and/or network plan set forth in

this Aact chapter or regulations or guidance promulgated thereunder.

     (10) "Emergency services" or "emergent services" means those resources provided in the

event of the sudden onset of a medical, behavioral health, or other health condition that the absence

of immediate medical attention could reasonably be expected, by a prudent layperson, to result in

placing the patient's health in serious jeopardy, serious impairment to bodily or mental functions,

or serious dysfunction of any bodily organ or part.

     (11) "Health benefit plan" or "health plan" means a policy, contract, certificate, or

agreement entered into, offered, or issued by a health care entity to provide, deliver, arrange for,

pay for, or reimburse any of the costs of health care services.

     (12) "Health care entity" means an insurance company licensed, or required to be licensed,

by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner or the

jurisdiction of the department of business regulation that contracts or offers to contract, or enters

into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health

care services, including, without limitation,: a for-profit or nonprofit hospital, medical or dental

service corporation or plan, a health maintenance organization, a health insurance company, or any

other entity providing health insurance, accident and sickness insurance, health benefits, or health

care services.

     (13) "Health care services" means and includes, but is not limited to,: an admission,

diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling

of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care

services, activities, or supplies that are covered by the beneficiary's health benefit plan.

     (14) "Most-favored-rate clause" means a provision in a provider contract whereby the rates

or fees to be paid by a health care entity are fixed, established, or adjusted to be equal to or lower

than the rates or fees paid to the provider by any other health care entity.

     (15) "Network" means the group or groups of participating providers providing health care

services under a network plan.

     (16) "Network Plan" means a health benefit plan or health plan that either requires a

beneficiary to use, or creates incentives, including financial incentives, for a beneficiary to use the

providers managed, owned, under contract with, or employed by the health care entity.

     (17) "Office" means the office of the health insurance commissioner.

     (18) "Professional provider" means an individual provider or health care professional

licensed, accredited, or certified to perform specified health care services consistent with state law

and who provides these health care services and is not part of a separate facility or institutional

contract.

     (19) "Provider" means a physician, hospital, professional provider, pharmacy, laboratory,

dental, medical, or behavioral health provider, or other state-licensed or other state-recognized

provider of health care or behavioral health services or supplies.

     (20) "Tiered network" means a network that identifies and groups some or all types of

providers into specific groups to which different provider reimbursement, beneficiary cost-sharing,

or provider access requirements, or any combination thereof, apply for the same services.

     27-18.8-3. Certification of network plans.

     (a) Certification and Recertification Process.

     (1) A health care entity operating a network plan shall not enroll consumers into its plan

unless the office has certified the network plan meeting the requirements herein.

     (2) The commissioner shall act upon the health care entities' completed applications for

certification of network plans, as determined by the commissioner, within ninety (90) calendar days

of receipt of such applications for certification.

     (3) To ensure compliance, the commissioner shall establish procedures for the periodic

review and recertification of network plans at least every three (3) years; provided, however, that

the commissioner may review the certification of a network plan at any time and/or may require

periodic compliance attestation from a health care entity if, in the commissioner's discretion, he or

she deems it appropriate to do so.

     (4) Cost of certification. The total cost of obtaining and maintaining a certificate under this

title and in compliance with the requirements of the applicable rules and regulations shall be borne

by the applicant and shall include one hundred fifty percent (150%) of the total salaries paid to the

personnel engaged in certifications and ensuring compliance with the requirements herein and the

applicable rules and regulations. These monies shall be paid to the commissioner to and for the use

of the office and shall be in addition to any taxes and fees otherwise payable to the state.

     (b) General requirements. The commissioner shall establish standards and procedures for

the certification of network plans that have demonstrated the ability to ensure that health care

services will be provided in a manner to assure ensure availability and accessibility, adequate

personnel and facilities, and continuity of service, and have demonstrated arrangements for ongoing

quality-assurance programs regarding care processes and outcomes. These standards shall consist

of, but are not limited to, the following:

     (1) As to each network plan, a health care entity must demonstrate it has a mechanism for

beneficiaries and providers to appeal and grieve decisions and actions of the network plan and/or

health care entity, including decisions or actions made by a delegate of the health care entity in

relation to the network plan;

     (2) As to each network plan, a health care entity must maintain a comprehensive list of

participating providers that meets the requirements herein and provides additional information

relevant to network adequacy;

     (3) In the event of any substantial systemic changes in the health care entity, network plan,

or any relevant delegate's certification information on file with the office, the health care entity

shall submit notice and explanation of this change for approval by the commissioner at least thirty

(30) calendar days prior to implementation of any such change;

     (4) As to each network plan, a health care entity shall maintain a complaint resolution

process acceptable to the office, whereby beneficiaries, their authorized representatives, their

physicians, or other health care providers may seek resolution of complaints and other matters of

which the health care entity has received oral or written notice;

     (5) As to each network plan, a health care entity shall be required to establish a mechanism,

under which providers, including local providers participating in the network plans, provide input

into the plan's health care policy, including: technology, medications and procedures, utilization

review criteria and procedures, quality and credentialing criteria, and medical management

procedures;

     (6) As to each network plan, a health care entity shall be required to establish a mechanism

under which beneficiaries provide input into the health care entity's procedures and processes

regarding the delivery of health care services; and

     (7) As to each network plan, a health care entity must maintain a process, policies, and

procedures for the modification of formularies to include notices to beneficiaries and providers

when formularies change in accordance with all state and federal laws.

     (c) Network requirements. For each network plan, health care entities must ensure the

following requirements are met:

     (1) Maintain access to professional, facility, and other providers sufficient to provide

coverage in a timely manner, of the benefits covered in the network plan and in a manner to assure

that all covered services will be accessible without unreasonable delay;

     (2) Establish a process acceptable to the commissioner to monitor the status of each

network plan's network adequacy not less frequently than quarterly;

     (3) Establish and maintain a transition-of-care policy and process when a network has been

narrowed, tiered, and/or providers (facilities and professional) have terminated contracts with the

health care entity for that network plan;

     (4) Establish a mechanism to provide the beneficiaries and consumers with up-to-date

information on providers, in a form acceptable to the commissioner, to include:

     (i) Location by city, town, county;

     (ii) Specialty practice areas;

     (iii) Affiliations/Admission/Privileges with facilities, including whether those facilities are

in-network facilities; and

     (iv) Whether the provider is accepting new patients.

     (d) Contracting and credentialing requirements.

     (1) A health care entity shall not refuse to contract with, or compensate for, covered

services of an otherwise eligible provider or non-participating provider solely because that provider

has, in good faith, communicated with one or more of their patients regarding the provisions, terms,

or requirements of the health care entity's products as they relate to the needs of that provider's

patients.

     (2) The health care entity or network plan provider contracting and credentialing process

shall include the following:

     (i) This credentialing process shall begin upon acceptance of a completed application from

a provider to the health care entity or network plan for inclusion;

     (ii) Each application shall be reviewed by the health care entity's or network plan's

credentialing body; and

     (iii) All health care entities or network plans shall develop and maintain credentialing

criteria to be utilized in adding to provider networks. Credentialing criteria shall be based on input

from providers credentialed in the health care entity or network plan and these standards shall be

available to applicants. When economic considerations are part of the decisions, the criteria must

be available to applicants. Any economic profiling must factor the specialty, utilization and practice

patterns, and general information comparing the applicant to their peers in the same specialty will

be made available. Any economic profiling of providers must be adjusted to recognize case mix,

severity of illness, age of patients, and other features of a provider's practice that may account for

higher than or lower than expected costs. Profiles must be made available to those so profiled.

     (3) A health care entity or network plan shall not exclude a professional provider of covered

services from participation in its provider network based solely on:

     (i) The professional provider's degree or license as applicable under state law; or

     (ii) The professional provider of covered services’ lack of affiliation with, or admitting

privileges at, a hospital, if that lack of affiliation is due solely to the professional provider's type of

license.

     (4) As to any network plan, health care entities shall not discriminate against providers

solely because the provider treats a substantial number of patients who require expensive or

uncompensated medical care.

     (5) The applicant shall be provided with all reasons used if the application is denied.

     (6) Health care entities or network plans shall not be allowed to include clauses in physician

or other provider contracts that allow for the health care entity or network plan to terminate the

contract "without cause"; provided, however, cause shall include lack of need due to economic

considerations.

     (7) There shall be due process for professional providers for all adverse decisions resulting

in a change of privileges or contractual language of a credentialed professional provider.

     (i) The details of the health care entity or network plan's due process shall be included in

the professional provider contracts.

     (ii) A health care entity or network plan is deemed to have met the adequate notice-and-

hearing requirement of this section with respect to a professional provider if the following

conditions are met (or are waived voluntarily by the professional provider):

     (A) The professional provider shall be notified of the proposed actions and the reasons for

the proposed action;

     (B) The professional provider shall be given the opportunity to contest the proposed action;

and

     (C) The health care entity has developed an appeals process that has reasonable time limits

for the resolution of the appeal.

     (8) A health care entity or network plan shall not include a most-favored-rate clause in a

provider contract.

     (9) A health entity or network plan may materially modify the terms of a participating

agreement it maintains with a professional provider only if it disseminates, in writing, by mail or

by electronic means to the professional provider, the contents of the proposed modification and an

explanation, in non-technical terms, of the modification's impact.

     (10) The health care entity or network plan shall provide the professional provider an

opportunity to amend or terminate the professional provider contract within sixty (60) calendar

days of receipt of the notice of modification. Any termination of a professional provider contract

made pursuant to this section shall be effective fifteen (15) calendar days from the mailing of the

notice of termination, in writing, by mail to the health care entity or network plan. The termination

shall not affect the method of payment or reduce the amount of reimbursement to the professional

provider by the health care entity or network plan for any beneficiary in active treatment for an

acute medical condition at the time the beneficiary's professional provider terminates their his or

her professional provider contract with the health care entity or network plan until the active

treatment is concluded or, if earlier, one year after the termination; and, with respect to the

beneficiary, during the active treatment period the professional provider shall be subject to all the

terms and conditions of the terminated professional provider contract, including, but not limited to,

all reimbursement provisions which that limit the beneficiary's liability.

     27-18.8-4. Contracts with providers for dental services.

     (a) No contract between a dental plan of a health care entity and a dentist for the provision

of services to beneficiaries may require that a dentist provide services to its patients at a fee set by

the health care entity unless said services are covered services under the applicable subscriber

agreement. "Covered services," as used herein, means services reimbursable under the applicable

beneficiary agreement, subject to such contractual limitations on beneficiary benefits as may apply,

including, for example, deductibles, waiting period, or frequency limitations.

     27-18.8-5. Contracts with providers and or optometric services.

     (a) No contract between an eye care provider and a health care entity or vision plan may

require that an eye care provider provide services or materials to its beneficiaries at a fee set by the

insurer or vision plan, unless the insurer or vision plan compensates the eye care provider for the

provision of such services or materials to the beneficiary. Reimbursement paid by the insurer or

vision plan for covered services and materials shall not provide nominal reimbursement in order to

claim that services and materials are covered services.

     (b)(1) "Services" means services and materials for which reimbursement from the vision

plan is provided for by a beneficiary's plan contract, or for which a reimbursement would be

available but for the application of the beneficiary's contractual limitations of deductibles,

copayments, or coinsurance.

     (2) "Materials" means and includes, but is not limited to,: lenses, devices containing lenses,

prisms, lens treatments and coatings, contact lenses, orthoptics, vision training, and prosthetic

devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa.

     (3) "Eye care provider" means an optometrist, optician, or ophthalmologist.

     27-18.8-6. Reporting requirements.

     The office shall establish reporting requirements to determine if health care entities and/or

network plans are in compliance with the provisions of this chapter and applicable regulations as

well as in compliance with applicable federal law.

     27-18.8-7. Rules and regulations.

     The health insurance commissioner may promulgate such rules and regulations as are

necessary and proper to effectuate the purpose and for the efficient administration and enforcement

of this chapter.

     27-18.8-8. Denial, suspension, or revocation of certificate.

     Adopted pursuant to this chapter;

     (a) The office may deny a certificate or certification upon review of the application if, upon

review of the application, it finds that the applicant proposing to establish a network plan does not

meet the standards required by this chapter or by any regulations promulgated pursuant to this

chapter.

     (b) The office may revoke or suspend a certificate or certification and/or impose monetary

penalties not less than one hundred dollars ($100) and not to exceed fifty thousand dollars ($50,000)

per violation and/or impose an order requiring a monetary restitution or disgorgement payment in

an amount determined by the commissioner to reasonably reflect the amount of damages caused or

monies improperly obtained in any case in which:

     (1) The network plan and/or health care entity fails to comply with the requirements of this

chapter or of regulations;

     (2) The network plan and/or health care entity fails to comply with the criteria used by it

in its application for a certificate or certification; or

     (3) The network plan and/or health care entity refuses to permit or fails to reasonably

cooperate with an examination by the commissioner to determine compliance with the requirements

of this chapter and regulations promulgated pursuant to the authority granted to the commissioner

in this chapter. These determinations may involve consideration of any written grievances filed

with the office against the network plan or health care entity by patients or providers.

     (c) Any applicant for certification or certificate holder aggrieved by an order or a decision

of the commissioner made under this chapter without a hearing may, within thirty (30) days after

notice of the order or decision, make a written request to the office for a hearing on the order or

decision pursuant to §42-35-15.

     (d) The procedure governing hearings authorized by this section shall be in accordance

with §§42-35-9 through 42-35-13 as stipulated in §42-35-14(a). A full and complete record shall

be kept of all proceedings, and all testimony shall be recorded but need not be transcribed unless

the decision is appealed pursuant to §42-35-15. A copy or copies of the transcript may be obtained

by any interested party upon payment of the cost of preparing the copy or copies. Witnesses may

be subpoenaed by either party.

     27-18.8-9. Penalties and enforcement.

     For the purposes of this chapter, in addition to the provisions of §27-18.8-8, a health care

entity or any person or entity conducting any activities requiring certification under this chapter

shall be subject to the penalty and enforcement provisions of title 27 this title and chapters 14 and

14.5 of title 42 and the regulations promulgated thereunder in the same manner as a licensee or any

person or entity conducting any activities requiring licensure or certification under title 27 this title.

     27-18.8-10. Severability.

     If any section, clause, or provision of this chapter shall be held either unconstitutional or

ineffective in whole or in part, to the extent that it is not unconstitutional or ineffective, it shall be

valid and effective and no other section, clause or provision shall on account thereof be termed

invalid or ineffective.

     SECTION 5. Title 27 of the General Laws entitled "INSURANCE" is hereby amended by

adding thereto the following chapter:

CHAPTER 18.9

BENEFIT DETERMINATION AND UTILIZATION REVIEW ACT

     27-18.9-1. Purpose of chapter.

     (a) The purpose of this chapter is to:

     (1) Promote the delivery of quality health care in a cost-effective manner;

     (2) Foster greater coordination between health care providers, patients, health care entities,

health benefit plans and utilization-review entities to ensure public health well-being;

     (3) Protect beneficiaries, businesses, and providers by ensuring that review agents are

qualified to perform review activities and to make informed decisions on the medical necessity and

appropriateness of medical care;

     (4) Ensure that review agents maintain the confidentiality of medical records in accordance

with applicable state and federal laws; and

     (5) Interface and maintain compliance with federal benefit determination and adverse

benefit determination requirements.

     (b) Nothing in this chapter is intended to prohibit or discourage the health insurance

commissioner from consulting or collaborating with the department of health, or any other state or

federal agency, to the extent the commissioner in his or her discretion determines such consultation

and/or collaboration is necessary and/or appropriate for the administration and enforcement of this

chapter.

     27-18.9-2. Definitions.

     As used in this chapter, the following terms are defined as follows:

     (1) "Adverse benefit determination" means a decision not to authorize a health care service,

including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole

or in part, for a benefit. A decision by a utilization-review agent to authorize a health care service

in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute

an adverse determination if the review agent and provider are in agreement regarding the decision.

Adverse benefit determinations include:

     (i) "Administrative adverse benefit determinations," meaning any adverse benefit

determination that does not require the use of medical judgment or clinical criteria such as a

determination of an individual's eligibility to participate in coverage, a determination that a benefit

is not a covered benefit, or any rescission of coverage; and

     (ii) "Non-administrative adverse benefit determinations," meaning any adverse benefit

determination that requires or involves the use of medical judgement or clinical criteria to

determine whether the service being reviewed is medically necessary and/or appropriate. This

includes the denial of treatments determined to be experimental or investigational, and any denial

of coverage of a prescription drug because that drug is not on the health care entity's formulary.

     (2) "Appeal" or "internal appeal" means a subsequent review of an adverse benefit

determination upon request by a claimant to include the beneficiary or provider to reconsider all or

part of the original adverse benefit determination.

     (3) "Authorization" means a review by a review agent, performed according to this act

chapter, concluding that the allocation of health care services ordered by a provider, given or

proposed to be given to a beneficiary, was approved or authorized.

     (4) "Authorized representative" means an individual acting on behalf of the beneficiary and

shall include: the ordering provider,; any individual to whom the beneficiary has given express

written consent to act on his or her behalf,; a person authorized by law to provide substituted

consent for the beneficiary; and, when the beneficiary is unable to provide consent, a family

member of the beneficiary.

     (5) "Beneficiary" means a policy-holder subscriber, enrollee, or other individual

participating in a health benefit plan.

     (6) "Benefit determination" means a decision to approve or deny a request to provide or

make payment for a health care service or treatment.

     (7) "Certificate" means a certificate granted by the commissioner to a review agent meeting

the requirements of this act chapter.

     (8) "Claim" means a request for plan benefit(s) made by a claimant in accordance with the

health care entity's reasonable procedures for filing benefit claims. This shall include pre-service,

concurrent, and post-service claims.

     (9) "Claimant" means a health care entity participant, beneficiary, and/or authorized

representative who makes a request for plan benefit(s).

     (10) "Commissioner" means the health insurance commissioner.

     (11) "Complaint" means an oral or written expression of dissatisfaction by a beneficiary,

authorized representative, or a provider. The appeal of an adverse benefit determination is not

considered a complaint.

     (12) "Concurrent assessment" means an assessment of health care services conducted

during a beneficiary's hospital stay, course of treatment or services over a period of time, or for the

number of treatments. If the medical problem is ongoing, this assessment may include the review