Rhode Island General Laws 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.
Terms Used In Rhode Island General Laws 27-20.1-19
- 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.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Dental service: means the professional services rendered by persons duly licensed under the laws of this state to practice dentistry, and prosthetic dentures, bridges, appliances, or other structures to be used and worn as substitutes for natural teeth, prosthetic appliances, orthodontic appliances, precious metal, and ceramic restorations, necessary in connection with the services and supplied by licensed persons, and drugs, medicines, supplies, and nursing care necessary in connection with the services, or expense indemnity for the services, prosthetic dentures, bridges, appliances, or other structures to be used and worn as substitutes for natural teeth, prosthetic appliances, orthodontic appliances, precious metal, and ceramic restorations, drugs, medicines, supplies, and care, as may be specified in any nonprofit dental service plan. See Rhode Island General Laws 27-20.1-1
(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.