Rhode Island General Laws 27-20.11-4. Medical necessity and appropriateness of treatment
(a) Upon request of the reimbursing health insurance carrier, all providers shall furnish medical records or other necessary data which substantiates that initial or continued treatment is at all times medically necessary and appropriate.
Terms Used In Rhode Island General Laws 27-20.11-4
- 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.
- carrier: means any entity subject to the insurance laws and regulations of this state, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation, an insurance company offering accident and sickness insurance, a health maintenance organization, a nonprofit hospital, medical service corporation, or any other entity subject to chapter 18, 19, 20, or 41 of this title, providing a plan of health insurance, health benefits, or health services. See Rhode Island General Laws 27-20.11-2
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- in writing: include printing, engraving, lithographing, and photo-lithographing, and all other representations of words in letters of the usual form. See Rhode Island General Laws 43-3-16
(b) Medical necessity criteria may be based in part on evidence of continued improvement as a result of treatment. When the provider cannot establish the medical necessity and/or appropriateness of the treatment modality being provided, neither the health insurer nor the patient shall be obligated to reimburse for that period or type of care that was not established. The exception to the preceding can only be made if the patient has been informed of the provisions of this subsection and has agreed in writing to continue to receive treatment at his or her own expense.
(c) Any subscriber who is aggrieved by a denial of benefits provided under this chapter may appeal a denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of Title 23 [repealed].
(d) A health insurance carrier may require submission of a treatment plan, including the frequency and duration of treatment, signed by a child psychiatrist, a behavioral developmental pediatrician, a child neurologist, or a licensed psychologist with training in child psychology, that the treatment is medically necessary for the patient and is consistent with nationally recognized treatment standards for the condition such as those set forth by the American Academy of Pediatrics. An insurer may require an updated treatment plan no more frequently than on a quarterly basis.
History of Section.
P.L. 2011, ch. 159, § 1; P.L. 2011, ch. 175, § 1.