Rhode Island General Laws 27-18.9-13. Denial, suspension, or revocation of certificate – Penalties
Adopted pursuant to this chapter;
(a) The office may deny a certificate or certification upon review of the application if, upon review of the application, it finds that the applicant proposing to conduct utilization review does not meet the standards required by this chapter or by any regulations promulgated pursuant to this chapter.
(b) The office may revoke or suspend a certificate or certification and/or impose monetary penalties not less than one hundred dollars ($100) and not to exceed fifty thousand dollars ($50,000) per violation and/or impose an order requiring a monetary restitution or disgorgement payment in an amount determined by the commissioner to reasonably reflect the amount of damages caused or monies improperly obtained in any case in which:
(1) The healthcare entity and/or review agent fails to comply with the requirements of this chapter or of regulations;
(2) The review agent/network plan and/or healthcare entity and/or review agent fails to comply with the criteria used by it in its application for a certificate or certification; or
(3) The healthcare entity and/or review agent refuses to permit or fails to reasonably cooperate with an examination by the commissioner to determine compliance with the requirements of this chapter and regulations promulgated pursuant to the authority granted to the commissioner in this chapter. These determinations may involve consideration of any written grievances filed with the office against the healthcare entity and/or review agent by patients or providers.
(c) Any applicant or certificate or certification holder aggrieved by an order or a decision of the commissioner made under this chapter without a hearing may, within thirty (30) days after notice of the order or decision, make a written request to the office for a hearing on the order or decision pursuant to § 42-35-15.
(d) The procedure governing hearings authorized by this section shall be in accordance with § 42-35-9 through § 42-35-13 as stipulated in § 42-35-14(a). A full and complete record shall be kept of all proceedings, and all testimony shall be recorded but need not be transcribed unless the decision is appealed pursuant to § 42-35-15. A copy or copies of the transcript may be obtained by any interested party upon payment of the cost of preparing the copy or copies. Witnesses may be subpoenaed by either party.
History of Section.
P.L. 2017, ch. 302, art. 5, § 5.
Terms Used In Rhode Island General Laws 27-18.9-13
- Certificate: means a certificate granted by the commissioner to a review agent meeting the requirements of this chapter. See Rhode Island General Laws 27-18.9-2
- Commissioner: means the health insurance commissioner. See Rhode Island General Laws 27-18.9-2
- Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
- 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
- Office: means the office of the health insurance commissioner. See Rhode Island General Laws 27-18.9-2
- Restitution: The court-ordered payment of money by the defendant to the victim for damages caused by the criminal action.
- 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
- Testimony: Evidence presented orally by witnesses during trials or before grand juries.
- Transcript: A written, word-for-word record of what was said, either in a proceeding such as a trial or during some other conversation, as in a transcript of a hearing or oral deposition.
- 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