Chapter 395

2013 -- S 0536 SUBSTITUTE A

Enacted 07/15/13

A N A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

Introduced By: Senators Goldin, Cool Rumsey, Conley, Satchell, and Sosnowski

Date Introduced: February 28, 2013

It is enacted by the General Assembly as follows:

SECTION 1. Section 27-18-65 of the General Laws in Chapter 27-18 entitled "Accident

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

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 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 subject to a pattern of

inappropriate billing, are related to coordination of benefits, are duplicate claims, 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 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, "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.

(d) Except for those contracts where the health insurer or plan has the right to unilaterally

amend the terms of the contract, the parties shall be able to negotiate contract terms which allow

for different time frames than is prescribed herein.

SECTION 2. Section 27-19-56 of the General Laws in Chapter 27-19 entitled "Nonprofit

Hospital Service Corporations" is hereby amended to read as follows:

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 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 subject to a

pattern of inappropriate billing, are related to coordination of benefits, are duplicate claims, 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 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, "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.

(d) Except for those contracts where the health insurer or plan has the right to unilaterally

amend the terms of the contract, the parties shall be able to negotiate contract terms which allow

for different time frames than is prescribed herein.

SECTION 3. Section 27-20-51 of the General Laws in Chapter 27-20 entitled "Nonprofit

Medical Service Corporations" is hereby amended to read as follows:

27-20-51. Post-payment audits. -- (a) Except as otherwise provided herein, any

review, audit or investigation by a nonprofit hospital medical 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 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 subject to a

pattern of inappropriate billing, are related to coordination of benefits, are duplicate claims, 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 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, "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.

(d) Except for those contracts where the health insurer or plan has the right to unilaterally

amend the terms of the contract, the parties shall be able to negotiate contract terms which allow

for different time frames than is prescribed herein.

SECTION 4. Section 27-41-69 of the General Laws in Chapter 27-41 entitled "Health

Maintenance Organizations" is hereby amended to read as follows:

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 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 subject to a pattern of

inappropriate billing, are related to coordination of benefits, are duplicate claims, 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 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, "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.

(d) Except for those contracts where the health insurer or plan has the right to unilaterally

amend the terms of the contract, the parties shall be able to negotiate contract terms which allow

for different time frames than is prescribed herein.

SECTION 5. This act shall take effect on January 1, 2014.

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LC01274/SUB A

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