2014 -- H 7790 SUBSTITUTE A
Enacted 06/30/14
A N A C T
RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES
Introduced By: Representative Robert B.Jacquard
Date Introduced: March 04, 2014
It is enacted by the General Assembly as follows:
SECTION 1. Section 27-18-65 of the General Laws in Chapter 27-18 entitled "Accident and Sickness Insurance Policies" is hereby amended to read as follows:
27-18-65. Post-payment audits. [Effective January 1, 2014.] --
(a) Except as otherwise provided herein, any review, audit or investigation by
a health insurer or health plan of a health care provider's claims which that results
in the recoupment or set-off of funds previously paid to the health care
provider in respect to such claims shall be completed no later than eighteen
(18) months after the completed claims were initially paid. This section shall
not restrict any review, audit, or
investigation regarding claims that are submitted fraudulently,; are
subject to a pattern of inappropriate billing,; are related to coordination of benefits,; are
duplicate claims,; or are subject to any federal law or regulation
that permits claims review beyond the period provided herein.
(b) No health care provider shall seek reimbursement from a payer for underpayment of a claim later than eighteen (18) months from the date the first payment on the claim was made, except if the claim is the subject of an appeal properly submitted pursuant to the payer's claims appeal policies or the claim is subject to continual claims submission.
(c) For the purposes of this section,
"health care provider" means an individual clinician, either in
practice independently, or in a group,
who provides health care services, and otherwise
referred to as a non-institutional provider any healthcare facility, as defined in § 27-18-1.1 including
any mental health and/or substance abuse treatment facility, physician, or
other licensed practitioner as identified to the review agent as having primary
responsibility for the care, treatment, and services rendered to a patient.
(d) Except for those contracts where
the health insurer or plan has the right to unilaterally amend the terms of the
contract, the parties shall be able to negotiate contract terms which that allow
for different time frames than is prescribed herein.
SECTION 2. Section 27-19-56 of the General Laws in Chapter 27-19 entitled "Nonprofit Hospital Service Corporations" is hereby amended to read as follows:
27-19-56. Post-payment audits. [Effective January 1, 2014.] --
(a) Except as otherwise provided herein, any review, audit or investigation by
a nonprofit hospital service corporation of a health care provider's claims which that results
in the recoupment or set-off of funds previously paid to the health care
provider in respect to such claims shall be completed no later than eighteen
(18) months after the completed claims were initially paid. This section shall
not restrict any review, audit, or
investigation regarding claims that are submitted fraudulently,; are subject
to a pattern of inappropriate billing,; are related to coordination of benefits,; are
duplicate claims,; or are subject to any federal law or regulation
that permits claims review beyond the period provided herein.
(b) No health care provider shall seek reimbursement from a payer for underpayment of a claim later than eighteen (18) months from the date the first payment on the claim was made, except if the claim is the subject of an appeal properly submitted pursuant to the payer's claims appeal policies or the claim is subject to continual claims submission.
(c) For the purposes of this section,
"health care provider" means an individual clinician, either in
practice independently or in a group, who provides health care services, and otherwise referred to as a non-institutional provider
any healthcare facility, as defined in § 27-19-1
including any mental health and/or substance abuse treatment facility,
physician, or other licensed practitioner identified to the review agent as
having primary responsibility for the care, treatment, and services rendered to
a patient.
(d) Except for those contracts where the health insurer or plan has the right to unilaterally amend the terms of the contract, the parties shall be able to negotiate contract terms which allow for different time frames than is prescribed herein.
SECTION 3. Section 27-20-51 of the General Laws in Chapter 27-20 entitled "Nonprofit Medical Service Corporations" is hereby amended to read as follows:
27-20-51. Post-payment audits. [Effective January 1, 2014.] --
(a) Except as otherwise provided herein, any review, audit or investigation by
a nonprofit medical service corporation of a health care provider's claims which that results
in the recoupment or set-off of funds previously paid to the health care
provider in respect to such claims shall be completed no later than eighteen
(18) months after the completed claims were initially paid. This section shall
not restrict any review, audit, or
investigation regarding claims that are submitted fraudulently,; are
subject to a pattern of inappropriate billing,; are related to coordination of benefits,; are
duplicate claims,; or are subject to any federal law or regulation
that permits claims review beyond the period provided herein.
(b) No health care provider shall seek reimbursement from a payer for underpayment of a claim later than eighteen (18) months from the date the first payment on the claim was made, except if the claim is the subject of an appeal properly submitted pursuant to the payer's claims appeal policies or the claim is subject to continual claims submission.
(c) For the purposes of this section,
"health care provider" means an individual clinician, either in
practice independently or in a group, who provides health care services, and otherwise referred to as a non-institutional provider
any healthcare facility, as defined in § 27-20-1
including any mental health and/or substance abuse treatment facility,
physician, or other licensed practitioner identified to the review agent as
having primary responsibility for the care, treatment, and services rendered to
a patient.
(d) Except for those contracts where the health insurer or plan has the right to unilaterally amend the terms of the contract, the parties shall be able to negotiate contract terms which allow for different time frames than is prescribed herein.
SECTION 4. Section 27-41-69 of the General Laws in Chapter 27-41 entitled "Health Maintenance Organizations" is hereby amended to read as follows:
27-41-69. Post-payment audits. [Effective January 1, 2014.] --
(a) Except as otherwise provided herein, any review, audit or investigation by
a health maintenance organization of a health care provider's claims which that results
in the recoupment or set-off of funds previously paid to the health care
provider in respect to such claims shall be completed no later than eighteen
(18) months after the completed claims were initially paid. This section shall
not restrict any review, audit, or investigation regarding claims that
are submitted fraudulently,; are subject to a pattern of inappropriate
billing,;
are related to coordination of benefits,; are duplicate claims,; or are subject to any federal law or regulation
that permits claims review beyond the period provided herein.
(b) No health care provider shall seek reimbursement from a payer for underpayment of a claim later than eighteen (18) months from the date the first payment on the claim was made, except if the claim is the subject of an appeal properly submitted pursuant to the payer's claims appeal policies or the claim is subject to continual claims submission.
(c) For the purposes of this section,
"health care provider" means an individual clinician, either in
practice independently or in a group, who provides health care services, and otherwise referred to as a non-institutional provider
any healthcare facility, as defined in § 27-41-2
including any mental health and/or substance abuse treatment facility,
physician, or other licensed practitioner identified to the review agent as
having primary responsibility for the care, treatment, and services rendered to
a patient.
(d) Except for those contracts where the health insurer or plan has the right to unilaterally amend the terms of the contract, the parties shall be able to negotiate contract terms which allow for different time frames than is prescribed herein.
SECTION 5. This act shall take effect on January 1, 2015.
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LC005028/SUB A
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