2018 -- H 8207

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LC005685

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2018

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A N   A C T

RELATING TO INSURANCE -- MEDICAID ELIGIBLE NON-EMERGENCY MEDICAL

TRANSPORTATION ACT

     Introduced By: Representatives Cunha, Tobon, Shekarchi, and Shanley

     Date Introduced: May 17, 2018

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

     SECTION 1. Title 27 of the General Laws entitled "INSURANCE" is hereby amended

by adding thereto the following chapter:

CHAPTER 20.12

MEDICAID ELIGIBLE NON-EMERGENCY MEDICAL TRANSPORTATION ACT

     27-20.12-1. Definitions.

     For purposes of this chapter:

     (1) "Broker" means a Health Insurance Portability and Accountability Act (HIPAA, Pub.

L. 104-191, 110 Stat. 1936 enacted August 21, 1996) covered entity that contracts with the

executive office of health and human services to deliver non-emergency medical transport

services.

     (2) "Claim" means:

     (i) A bill or invoice for covered services;

     (ii) A line item of service; or

     (iii) All services for a provider within a bill or invoice.

     (3) "Date of receipt" means the date the broker receives the claim via electronic

submission.

     (4) "Medicaid non-emergency medical transportation program provider" or "provider"

means an entity that provides transportation for eligible Medicaid beneficiaries to and from non-

emergency medical appointments and services for those who have a legitimate need for the

transportation assistance.

     (5) "Substantial compliance" means that the broker is processing and paying ninety-five

percent (95%) or more of all claims within the time frame provided for in § 27-20.12-2(a).

     27-20.12-2. Prompt processing of claims.

     (a) Every Medicaid non-emergency medical transportation program broker ("broker")

operating in the state shall be in substantial compliance with this chapter, and must utilize a

billing and remittance system which maintains electronic data interchange ("EDI") compliance to

HIPAA 5010 guidelines for electronic transmission of health care payment and benefit

information by using standard EDI 835 and 837 transaction sets. Every broker shall pay all

complete claims for covered transportation services submitted to the broker by a Medicaid non-

emergency medical transportation provider ("provider") within fourteen (14) calendar days

following the date of receipt of a complete electronic claim. Claims shall be defined by current

HIPAA standards and EDI transaction sets and the broker shall distribute the standard to all

participating providers.

     (b) Every broker that denies or pends a claim, shall have ten (10) calendar days from

receipt of the claim to notify the provider, via EDI compliant remittance, of any and all reasons

for denying or pending the claim and what, if any, additional information is required to process

the claim. No broker may limit the time period in which additional information may be submitted

to complete a claim.

     (c) Any claim that is resubmitted by a provider shall be processed by the broker pursuant

to the provisions of subsection (a) of this section.

     (d) Every broker that fails to reimburse the provider after receipt by the broker of a

complete claim within the required timeframes shall pay to the provider who submitted the claim,

in addition to any reimbursement for transportation services provided, interest which shall accrue

at the rate of twelve percent (12%) per annum commencing on the fifteenth (15th) day after

receipt of a complete electronic claim and ending on the date the payment is issued to the

provider.

     (e) Any provision in any contract between the broker and provider which contains terms

inconsistent with this chapter shall be void as against public policy to the extent of the

inconsistencies.

     27-20.12-3. Exceptions to claim processing.

     (a) No broker operating within this state shall be in violation of this chapter for failure to

timely process a claim submitted by a provider if:

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     (1) Failure to comply is caused by a directive from a court or federal or state agency;

     (2) The broker is in liquidation or rehabilitation or is operating in compliance with a court

ordered plan of rehabilitation; or

     (3) The broker's compliance is rendered impossible due to matters beyond its control that

are not caused by it.

     (b) No broker operating in the state shall be in violation of this chapter for any claim:

     (1) Initially submitted more than ninety (90) days after the service is rendered; or

     (2) Re-submitted more than ninety (90) days after the date the provider received the

notice provided for in this section; provided, this exception shall not apply in the event

compliance is rendered impossible due to matters beyond the control of the provider and were not

caused by the provider.

     (c) No broker operating in the state shall be in violation of this chapter while the claim is

pending due to a fraud investigation by a state or federal agency.

     (d) No broker operating in the state shall be obligated under this chapter to pay interest to

any provider for any claim if the director of the department of business regulation finds that the

entity or plan is in substantial compliance with this section. A broker seeking such a finding from

the director shall submit any documentation that the director shall require. A broker which is

found to be in substantial compliance with this section shall thereafter submit any documentation

that the director may require on an annual basis for the director to assess ongoing compliance

with this section.

     27-20.12-4. Annual reporting.

     The executive office of health and human services shall annually report to the house and

senate finance committees the following information regarding brokers:

     (1) Total number of Medicaid recipients served in the non-emergency medical

transportation services (NEMT) program;

     (2) Total number of trips scheduled;

     (3) Total number of trips provided;

     (4) Total number of trips cancelled;

     (5) Total number of trips denied, including explanation for denial;

     (6) Average length of time to pay claims submitted by provider;

     (7) Number of providers participating in the program by year, beginning with FY 2017;

     (8) Average reimbursement rates for Rhode Island non-emergency medical

transportation, by trip category;

     (9) Average reimbursement rates for Massachusetts and Connecticut non-emergency

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medical transportation, by trip category;

     (10) Total number of complaints received, including information regarding source of the

complaint to include, but not limited to, complaints received from recipients, providers, facilities;

     (11) Percentage of cases for which claims have the required documentation from

provider;

     (12) Safety records from provider; and

     (13) Any instances of internal fraud or abuse including, but not limited to, fraud or abuse

committed by brokers or providers.

     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- MEDICAID ELIGIBLE NON-EMERGENCY MEDICAL

TRANSPORTATION ACT

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     This act would provide for the payment of Medicaid eligible non-emergency medical

transportation services within fourteen (14) days of submission of a completed claim and would

provide for twelve percent (12%) interest to be paid for late payment unless a specific condition

exists. This act would also mandate annual reporting by the executive office of health and human

services related to Medicaid eligible non-emergency medical transportation services.

     This act would take effect upon passage.

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