§ 27-41-69 Post-payment audits.
(a) Except as otherwise provided herein, any review, audit or investigation by a health maintenance organization of a health care provider's claims 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 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.
(P.L. 2006, ch. 86, § 5; P.L. 2006, ch. 97, § 5; P.L. 2013, ch. 251, § 4; P.L. 2013, ch. 395, § 4; P.L. 2014, ch. 201, § 4; P.L. 2014, ch. 214, § 4.)