(a) Procedural failure by claimant.

(1)  In the event of the failure of claimant or an authorized representative to follow the healthcare entities claims procedures for a pre-service claim the healthcare entity or its review agent must:

(i)  Notify claimant or the authorized representative, as appropriate, of this failure as soon as possible and no later than five (5) calendar days following the failure and this notification must also inform claimant of the proper procedures to file a pre-service claim; and

(ii)  Notwithstanding the above, if the pre-service claim relates to urgent or emergent healthcare services, the healthcare entity or its review agent must notify and inform claimant or the authorized representative, as appropriate, of the failure and proper procedures within twenty-four (24) hours following the failure. Notification may be oral, unless written notification is requested by the claimant or authorized representative.

(2)  Claimant must have stated name, specific medical condition or symptom and specific treatment, service, or product for which approval is requested and submitted to proper claim processing unit.

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Terms Used In Rhode Island General Laws 27-18.9-5

  • Adverse benefit determination: means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. See Rhode Island General Laws 27-18.9-2
  • Authorization: means a review by a review agent, performed according to this chapter, concluding that the allocation of healthcare services ordered by a provider, given or proposed to be given to a beneficiary, was approved or authorized. See Rhode Island General Laws 27-18.9-2
  • Authorized representative: means an individual acting on behalf of the beneficiary and shall include: the ordering provider; any individual to whom the beneficiary has given express written consent to act on his or her behalf; a person authorized by law to provide substituted consent for the beneficiary; and, when the beneficiary is unable to provide consent, a family member of the beneficiary. See Rhode Island General Laws 27-18.9-2
  • Claim: means a request for plan benefit(s) made by a claimant in accordance with the healthcare entity's reasonable procedures for filing benefit claims. See Rhode Island General Laws 27-18.9-2
  • Claimant: means a healthcare entity participant, beneficiary, and/or authorized representative who makes a request for plan benefit(s). See Rhode Island General Laws 27-18.9-2
  • Healthcare entity: means an insurance company licensed, or required to be licensed, by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of Title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. See Rhode Island General Laws 27-18.9-2
  • Healthcare services: means and includes, but is not limited to: an admission, diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care services, activities, or supplies that are covered by the beneficiary's health-benefit plan. See Rhode Island General Laws 27-18.9-2
  • Office: means the office of the health insurance commissioner. See Rhode Island General Laws 27-18.9-2
  • person: may be construed to extend to and include co-partnerships and bodies corporate and politic. See Rhode Island General Laws 43-3-6
  • Pre-service claim: means the request for a plan benefit(s) by a claimant prior to a service being rendered and is not considered a concurrent claim. See Rhode Island General Laws 27-18.9-2
  • Provider: means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies. See Rhode Island General Laws 27-18.9-2
  • Review agent: means a person or healthcare entity performing benefit determination reviews that is either employed by, affiliated with, under contract with, or acting on behalf of a healthcare entity. See Rhode Island General Laws 27-18.9-2
  • Utilization review: means the prospective, concurrent, or retrospective assessment of the medical necessity and/or appropriateness of the allocation of healthcare services of a provider, given or proposed to be given, to a beneficiary. See Rhode Island General Laws 27-18.9-2

(b) Utilization review agent procedural requirements:

(1)  All initial, prospective, and concurrent non-administrative, adverse benefit determinations of a healthcare service that had been ordered by a physician, dentist, or other practitioner shall be made, documented, and signed by a licensed practitioner with the same licensure status as the ordering provider;

(2)  Utilization review agents are not prohibited from allowing appropriately qualified review agency staff from engaging in discussions with the attending provider, the attending provider’s designee or appropriate healthcare facility and office personnel regarding alternative service and/or treatment options. Such a discussion shall not constitute an adverse benefit determination; provided, however, that any change to the attending provider’s original order and/or any decision for an alternative level of care must be made and/or appropriately consented to by the attending provider or the provider’s designee responsible for treating the beneficiary and must be documented by the review agent; and

(3)  A utilization review agent shall not retrospectively deny authorization for healthcare services provided to a covered person when an authorization has been obtained for that service from the review agent unless the approval was based upon inaccurate information material to the review or the healthcare services were not provided consistent with the provider’s submitted plan of care and/or any restrictions included in the prior approval granted by the review agent.

History of Section.
P.L. 2017, ch. 302, art. 5, § 5.