Chapter
086
2006 -- S 2758 SUBSTITUTE A
Enacted 06/13/06
A N A
C T
RELATING TO
POST-PAYMENT AUDIT RESTRICTIONS
Introduced By: Senator
Hanna M. Gallo
Date Introduced: February
14, 2006
It is
enacted by the General Assembly as follows:
SECTION
1. Chapter 27-18 of the General Laws entitled "Accident and Sickness
Insurance
Policies" is hereby amended by adding thereto the following section:
27-18-65.
Post-payment audits. – (a) Except as otherwise provided herein, any
review,
audit
or investigation by a health insurer or health plan of a health care provider's
claims which
results
in the recoupment or set-off of funds previously paid to the health care
provider in respect
to
such claims shall be completed no later than two (2) years after the completed
claims were
initially
paid. This section shall not restrict any review, audit or investigation
regarding claims
that
are submitted fraudulently, are subject to a pattern of inappropriate billing,
are related to
coordination
of benefits, or are subject to any federal law or regulation that permits
claims review
beyond
the period provided herein.
(b)
No health care provider shall seek reimbursement from a payer for underpayment
of a
claim
later than two (2) years 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, "health care provider" means an
individual clinician,
either
in practice independently or in a group, who provides health care services, and
otherwise
referred
to as a non-institutional provider.
SECTION
2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service
Corporations"
is hereby amended by adding thereto the following section:
27-19-56.
Post-payment audits. -- (a) Except as otherwise provided herein, any
review,
audit
or investigation by a nonprofit hospital service corporation of a health care
provider's claims
which
results in the recoupment or set-off of funds previously paid to the health
care provider in
respect
to such claims shall be completed no later than two (2) years after the
completed claims
were
initially paid. This section shall not restrict any review, audit or
investigation regarding
claims
that are submitted fraudulently, are subject to a pattern of inappropriate
billing, are related
to coordination
of benefits, or are subject to any federal law or regulation that permits
claims
review
beyond the period provided herein.
(b)
No health care provider shall seek reimbursement from a payer for underpayment
of a
claim
later than two (2) years 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, "health care provider" means an
individual clinician,
either
in practice independently or in a group, who provides health care services, and
otherwise
referred
to as a non-institutional provider.
SECTION
3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service
Corporations"
is hereby amended by adding thereto the following section:
27-20-51.
Post-payment audits. -- (a) Except as otherwise provided herein, any
review,
audit
or investigation by a nonprofit hospital service corporation of a health care
provider's claims
which
results in the recoupment or set-off of funds previously paid to the health
care provider in
respect
to such claims shall be completed no later than two (2) years after the
completed claims
were
initially paid. This section shall not restrict any review, audit or
investigation regarding
claims
that are submitted fraudulently, are subject to a pattern of inappropriate
billing, are related
to
coordination of benefits, or are subject to any federal law or regulation that
permits claims
review
beyond the period provided herein.
(b)
No health care provider shall seek reimbursement from a payer for underpayment
of a
claim
later than two (2) years 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, "health care provider" means an
individual clinician,
either
in practice independently or in a group, who provides health care services, and
otherwise
referred
to as a non-institutional provider.
SECTION
4. Chapter 27-20.1 of the General Laws entitled "Nonprofit Dental Service
Corporations"
is hereby amended by adding thereto the following section:
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 health care
provider's claims
which
results in the recoupment or set-off of funds previously paid to the health
care provider in
respect
to such claims shall be completed no later than two (2) years after the
completed claims
were
initially paid. This section shall not restrict any review, audit or
investigation regarding
claims
that are submitted fraudulently, are subject to a pattern of inappropriate
billing, are related
to
coordination of benefits, or are subject to any federal law or regulation that
permits claims
review
beyond the period provided herein.
(b)
No health care provider shall seek reimbursement from a payer for underpayment
of a
claim
later than two (2) years 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, "health care provider" means an individual
clinician,
either
in practice independently or in a group, who provides health care services, and
otherwise
referred
to as a non-institutional provider.
SECTION
5. Chapter 27-41 of the General Laws entitled "Health Maintenance
Organizations"
is hereby amended by adding thereto the following section:
27-41-69.
Post-payment audits. -- (a) Except as otherwise provided herein, any
review,
audit
or investigation by a health maintenance organization of a health care
provider's claims
which
results in the recoupment or set-off of funds previously paid to the health
care provider in
respect
to such claims shall be completed no later than two (2) years after the
completed claims
were initially
paid. This section shall not restrict any review, audit or investigation
regarding
claims
that are submitted fraudulently, are subject to a pattern of inappropriate
billing, are related
to
coordination of benefits, or are subject to any federal law or regulation that
permits claims
review
beyond the period provided herein.
(b)
No health care provider shall seek reimbursement from a payer for underpayment
of a
claim
later than two (2) years 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, "health care provider" means an individual
clinician,
either
in practice independently or in a group, who provides health care services, and
otherwise
referred
to as a non-institutional provider.
SECTION
6. This act shall take effect upon passage.
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LC01471/SUB A
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