§ 27-20.1-19. Post-payment audits.
(a) Except as otherwise provided herein, any review, audit, or investigation by a nonprofit dental service corporation of a healthcare provider’s claims that results in the recoupment or set-off of funds previously paid to the healthcare provider in respect to the 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 known, or should have been known, by the healthcare provider to be a pattern of inappropriate billing according to the standards for provider billing of their respective medical or dental specialty; are related to coordination of benefits; or are subject to any federal law or regulation that permits claims review beyond the period provided herein.
(b) No healthcare 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, “healthcare provider” means an individual clinician, either in practice independently or in a group, who provides healthcare services, and otherwise referred to as a non-institutional provider.
History of Section.
P.L. 2006, ch. 86, § 4; P.L. 2006, ch. 97, § 4; P.L. 2017, ch. 368, § 5; P.L. 2017,
ch. 375, § 5.