2018 -- H 7061 SUBSTITUTE A

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LC003167/SUB A

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2018

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A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     

     Introduced By: Representatives Craven, McEntee, and Lombardi

     Date Introduced: January 03, 2018

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

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     SECTION 1. Section 27-18-61 of the General Laws in Chapter 27-18 entitled "Accident

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and Sickness Insurance Policies" is hereby amended to read as follows:

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     27-18-61. Prompt processing of claims.

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     (a) A health care entity or health plan operating in the state shall pay all complete claims

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for covered health care services submitted to the health care entity or health plan by a health care

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provider or by a policyholder within forty (40) calendar days following the date of receipt of a

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complete written claim or within thirty (30) calendar days following the date of receipt of a

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complete electronic claim. Each health plan shall establish a written standard defining what

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constitutes a complete claim and shall distribute this standard to all participating providers.

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     (b) If the health care entity or health plan denies or pends a claim, the health care entity

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or health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing

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the health care provider or policyholder of any and all reasons for denying or pending the claim

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and what, if any, additional information is required to process the claim. No health care entity or

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health plan may limit the time period in which additional information may be submitted to

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complete a claim.

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     (c) Any claim that is resubmitted by a health care provider or policyholder shall be

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treated by the health care entity or health plan pursuant to the provisions of subsection (a) of this

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section.

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     (d) A health care entity or health plan which fails to reimburse the health care provider or

 

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policyholder after receipt by the health care entity or health plan of a complete claim within the

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required timeframes shall pay to the health care provider or the policyholder who submitted the

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claim, in addition to any reimbursement for health care services provided, interest which shall

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accrue at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day

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after receipt of a complete electronic claim or on the forty-first (41st) day after receipt of a

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complete written claim, and ending on the date the payment is issued to the health care provider

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or the policyholder.

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     (e) Exceptions to the requirements of this section are as follows:

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     (1) No health care entity or health plan operating in the state shall be in violation of this

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section for a claim submitted by a health care provider or policyholder if:

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     (i) Failure to comply is caused by a directive from a court or federal or state agency;

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     (ii) The health care entity or health plan is in liquidation or rehabilitation or is operating

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in compliance with a court-ordered plan of rehabilitation; or

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     (iii) The health care entity or health plan's compliance is rendered impossible due to

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matters beyond its control that are not caused by it.

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     (2) No health care entity or health plan operating in the state shall be in violation of this

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section for any claim: (i) initially submitted more than ninety (90) days after the service is

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rendered, or (ii) resubmitted more than ninety (90) days after the date the health care provider

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received the notice provided for in subsection (b) of this section; provided, this exception shall

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not apply in the event compliance is rendered impossible due to matters beyond the control of the

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health care provider and were not caused by the health care provider.

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     (3) No health care entity or health plan operating in the state shall be in violation of this

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section while the claim is pending due to a fraud investigation by a state or federal agency.

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     (4) No health care entity or health plan operating in the state shall be obligated under this

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section to pay interest to any health care provider or policyholder for any claim if the director of

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business regulation office of the health insurance commissioner (Commissioner) finds that the

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entity or plan is in substantial compliance with this section. A health care entity or health plan

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seeking such a finding from the director commissioner shall submit any documentation that the

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director commissioner shall require. A health care entity or health plan which is found to be in

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substantial compliance with this section shall thereafter submit any documentation that the

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director commissioner may require on an annual quarterly basis for the director commissioner to

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assess ongoing compliance with this section.

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     (5) A health care entity or health plan may petition the director for a waiver of the

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provision of this section for a period not to exceed ninety (90) days in the event the health care

 

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entity or health plan is converting or substantially modifying its claims processing systems.

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     (f) For purposes of this section, the following definitions apply:

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     (1) "Claim" means: (i) a bill or invoice for covered services; (ii) a line item of service; or

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(iii) all services for one patient or subscriber within a bill or invoice.

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     (2) "Date of receipt" means the date the health care entity or health plan receives the

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claim whether via electronic submission or as a paper claim.

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     (3) "Health care entity" means a licensed insurance company or nonprofit hospital or

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medical or dental service corporation or plan or health maintenance organization, or a contractor

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as described in § 23-17.13-2(2), which operates a health plan.

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     (4) "Health care provider" means an individual clinician, either in practice independently

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or in a group, who provides health care services, and otherwise referred to as a non-institutional

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provider or a certified community mental health center, opioid treatment provider or other non-

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CMHC providers of approved Medicaid services.

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     (5) "Health care services" include, but are not limited to, medical, mental health,

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substance abuse, dental and any other services covered under the terms of the specific health plan.

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     (6) "Health plan" means a plan operated by a health care entity that provides for the

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delivery of health care services to persons enrolled in those plans through:

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     (i) Arrangements with selected providers to furnish health care services; and/or

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     (ii) Financial incentive for persons enrolled in the plan to use the participating providers

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and procedures provided for by the health plan.

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     (iii) All persons enrolled and approved via the BHDDH portal.

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     (7) "Policyholder" means a person covered under a health plan or a representative

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designated by that person.

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     (8) "Substantial compliance" means that the health care entity or health plan is processing

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and paying ninety-five percent (95%) or more of all claims within the time frame provided for in

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subsections (a) and (b) of this section ratio by the number of claims paid or processed by a subject

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entity within the timeframes set forth in § 27-18-61(a) to the number of claims received, is 0.95

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or greater.

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     (i) To measure the level of substantial compliance with the parity statute, any health plan

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contracting with EOHHS must report prompt Medicaid claims processing of data by service line

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on a quarterly basis, and include the following information:

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     (A) Total number of claims received within the quarter;

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     (B) Total number of claims paid within statutory timeframes;

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     (C) Total number of claims paid outside of statutory timeframes;

 

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     (D) Average processing time (in days) for all claims paid within statutory timeframes;

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     (E) Average processing time (in days) for all claims paid outside of statutory timeframes;

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and

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     (F) Total interest paid on claims paid outside of statutory timeframes.

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     (ii) All data must be submitted within thirty (30) days following the close of the quarter.

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     (iii) If the health plan is meeting the federal and/or contractual Medicaid reimbursement

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requirements, but is processing and paying behavioral health claims in an unequitable manner, it

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will qualify as a non-quantitative insurer practice and sanctions will be applied through the office

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of the health insurance commissioner.

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     (g) Any provision in a contract between a health care entity or a health plan and a health

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care provider which is inconsistent with this section shall be void and of no force and effect.

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     (h) Pre-payment and timely payment. The executive office of health and human services

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(EOHHS) shall impose a timely claims processing and payment procedure for Medicaid services.

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If the health plan fails to reimburse the health care provider or policy holder within the required

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timeframes as outlined under subsection (a) of this section, EOHHS, office of Medicaid, will

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mandate under contractual agreement that the health plan execute a pre-payment reimbursement

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plan with agreement of the health care provider.

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     The pre-payment reimbursement plan shall require the health plan to pay a health care

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provider rendering opioid treatment program health home services; integrated health home

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services (IHH) including vocational and therapy services; assertive community treatment (ACT):

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mental health psychiatric rehabilitation residences (MHPRR); and substance use disorder

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residential treatment services.

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     Payment on a pre-payment basis shall require payment by the health plan on the first

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business day of each month with each payment amount equal to the average monthly payment

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received for individuals on the attribution list during the immediate preceding six (6) months.

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The health care provider and health plan shall undertake a reconciliation within one hundred

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eighty (180) days of the close of each quarter with any overpayment repaid by the health care

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provider or underpayment paid by the health plan within thirty (30) days.

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     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

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     This act would substitute the office of health insurance commissioner for the director the

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department business regulation as the overseer of health insurance claims, would amend the

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definitions of “health care provider”, “health care services”, and “substantial compliance” and

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would also set forth guidelines to use to determine whether substantial compliance has been met.

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It would also require the executive office of health and human services to impose a timely claims

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processing and payment procedure for Medicaid services.

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     This act would take effect upon passage.

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