Chapter 215

2007 -- S 0254 SUBSTITUTE A AS AMENDED

Enacted 07/02/07

A N A C T

RELATING TO INSURANCE -- HEALTH MAINTENANCE ORGANIZATIONS

Introduced By: Senators Gallo, and P Fogarty

Date Introduced: February 07, 2007

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 20.9

CONTRACT WITH HEALTH CARE PROVIDERS

27-20.9-1. Health care contracts – Required provisions - Definitions – (a) On and

after January 1, 2008, a health insurer that contracts with a health care provider shall comply with

the provisions of this chapter and shall include the provisions required by this chapter in the

health care contract. A contract in existence prior to January 1, 2008, that is renewed or renews

by its terms shall comply with the provisions of this chapter no later than December 31, 2008.

(b) As used in this chapter, unless the context otherwise requires:

(i) “Health care contract” means a contract entered into or renewed between a health

insurer and a health care provider for the delivery of health care services to others.

(ii) “Health care provider” means a person licensed or certified in this state to practice

medicine, pharmacy, chiropractic, nursing, physical therapy, podiatry, dentistry, optometry,

occupational therapy, or other healing arts.

(iii) “Health insurer” means every nonprofit medical service corporation, hospital service

corporation, health maintenance organization, or other insurer offering and/or insuring health

services; the term shall in addition include any entity defined as an insurer under section 42-62-4

and any third-party administrator when interacting with health care providers and enrollees on

behalf of such an insurer.

27-20.9-2. Credentialing -- Insurers shall notify providers of initial credentialing

within ten business days of approval by the insurer credentialing committee. – The health

insurer shall reimburse the health care provider for covered services rendered by the health care

provider to the health insurer's subscribers or members following the first business day after the

credentialing committee's approval, provided that the health care provider returns a signed health

care contract within fifteen (15) business days of receipt from the health insurer.

27-20.9-3. Pay-for-performance guidelines. – A health insurer shall not require a

physician, as a condition of contracting, to participate in any financial or reimbursement incentive

program, commonly referred to as pay-for-performance programs unless such program meets the

principles and guidelines for pay-for-performance programs endorsed by the national quality

forum and adopted by the AQA Alliance or the hospital quality alliance, or similar principles and

guidelines for pay-for-performance programs approved by the office of the health insurance

commissioner.

     SECTION 2. This act shall take effect upon passage.

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LC01395/SUB A/3

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