Chapter 000

Chapter 097

2006 -- H 7648 SUBSTITUTE A

Enacted 06/13/16

A N A C T

RELATING TO POST-PAYMENT AUDIT RESTRICTIONS

Introduced By: Representatives Lewiss, Kennedy, Sullivan, Ginaitt, and Anguilla

Date Introduced: February 16, 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.

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.

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.

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.

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.

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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LC01048/SUB A

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