2007 -- S 0254 SUBSTITUTE A AS AMENDED
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:
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
SECTION 2. This act shall take effect upon passage.