(a)  Except as otherwise provided herein, any review, audit, or investigation by a health maintenance organization 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 such claims shall be completed no later than eighteen (18) months after the completed claims were initially paid, except that the period for recoupment or set-off for claims submitted by a mental health and/or substance use disorder provider, for those services, licensed by this state, and participating with the health insurer or health plan, shall be no later than twelve (12) months. 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 specialties; 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.

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Terms Used In Rhode Island General Laws 27-41-69

  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Contract: A legal written agreement that becomes binding when signed.
  • Health maintenance organization: means a single public or private organization that:

    (i)  Provides or makes available to enrolled participants healthcare services, including at least the following basic healthcare services: usual physician services, hospitalization, laboratory, x-ray, emergency, and preventive services, and out-of-area coverage, and the services of licensed midwives;

    (ii)  Is compensated, except for copayments, for the provision of the basic healthcare services listed in subsection (20)(i) of this section to enrolled participants on a predetermined periodic rate basis;

    (iii)(A)  Provides physicians' services primarily:

    (I)  Directly through physicians who are either employees or partners of the organization; or

    (II)  Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice basis;

    (B)  "Health maintenance organization" does not include prepaid plans offered by entities regulated under chapter 1, 2, 19, or 20 of this title that do not meet the criteria above and do not purport to be health maintenance organizations; and

    (iv)  Provides the services of licensed midwives primarily:

    (A)  Directly through licensed midwives who are either employees or partners of the organization; or

    (B)  Through arrangements with individual licensed midwives or one or more groups of licensed midwives organized on a group practice or individual practice basis. See Rhode Island General Laws 27-41-2

  • Healthcare facility: means an institution providing healthcare services or a healthcare setting, including, but not limited, to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings. See Rhode Island General Laws 27-41-2
  • Healthcare services: means any services included in the furnishing to any individual of medical, podiatric, or dental care, or hospitalization, or incident to the furnishing of that care or hospitalization, and the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability. See Rhode Island General Laws 27-41-2
  • Physician: includes a podiatrist as defined in chapter 29 of Title 5. See Rhode Island General Laws 27-41-2
  • provider: means a healthcare professional or a healthcare facility. See Rhode Island General Laws 27-41-2

(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 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 that allow for different time frames than are prescribed herein.

History of Section.
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; P.L. 2017, ch. 368, § 4; P.L. 2017, ch. 375, § 4; P.L. 2022, ch. 157, § 4, effective June 27, 2022; P.L. 2022, ch. 158, § 4, effective June 27, 2022.