Chapter 158
2022 -- H 7344 SUBSTITUTE A
Enacted 06/27/2022

A N   A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

Introduced By: Representative Brandon C. Potter

Date Introduced: February 04, 2022

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 healthcare provider's claims that results in the recoupment or set-off of
funds previously paid to the healthcare provider in respect to such claims shall be completed no
later than eighteen (18) months after the completed claims were initially paid, except that the period
for recoupment or set-off for claims submitted by a mental health and/or substance use disorder
provider, for those services, licensed by this state, and participating with the health insurer or health
plan, shall be no later than twelve (12) months. This section shall not restrict any review, audit, or
investigation regarding claims that are submitted fraudulently; are known, or should have been
known, by the healthcare provider to be a pattern of inappropriate billing according to the standards
for provider billing of their respective medical or dental specialties; 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 healthcare provider shall seek reimbursement from a payer for underpayment of a
claim later than 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, "healthcare provider" means an individual clinician,
either in practice independently or in a group, who provides healthcare services, and any healthcare
facility, as defined in § 27-18-1.1, including any mental health and/or substance abuse treatment
facility, physician, or other licensed practitioner as identified to the review agent as having primary
responsibility for the care, treatment, and services rendered to a patient.
     (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 that allow for
different time frames than is are 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 healthcare provider's claims that results in the recoupment or set-
off of funds previously paid to the healthcare provider in respect to such claims shall be completed
no later than eighteen (18) months after the completed claims were initially paid, except that the
period for recoupment or set-off for claims submitted by a mental health and/or substance use
disorder provider, for those services, licensed by this state, and participating with the health insurer
or health plan, shall be no later than twelve (12) months. This section shall not restrict any review,
audit, or investigation regarding claims that are submitted fraudulently; are known, or should have
been known, by the healthcare provider to be a pattern of inappropriate billing according to the
standards for provider billing of their respective medical or dental specialties; 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 healthcare provider shall seek reimbursement from a payer for underpayment of a
claim later than 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, "healthcare provider" means an individual clinician,
either in practice independently or in a group, who provides healthcare services, and any healthcare
facility, as defined in § 27-18-1.1, including any mental health and/or substance abuse treatment
facility, physician, or other licensed practitioner identified to the review agent as having primary
responsibility for the care, treatment, and services rendered to a patient.
     (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 that allow for
different time frames than is are 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
medical service corporation of a healthcare provider's claims that results in the recoupment or set-
off of funds previously paid to the healthcare provider in respect to such claims shall be completed
no later than eighteen (18) months after the completed claims were initially paid, except that the
period for recoupment or set-off for claims submitted by a mental health and/or substance use
disorder provider, for those services, licensed by this state, and participating with the health insurer
or health plan, shall be no later than twelve (12) months. This section shall not restrict any review,
audit, or investigation regarding claims that are submitted fraudulently; are known, or should have
been known, by the healthcare provider to be a pattern of inappropriate billing according to the
standards for provider billing of their respective medical or dental specialties; 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 healthcare provider shall seek reimbursement from a payer for underpayment of a
claim later than 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, "healthcare provider" means an individual clinician,
either in practice independently or in a group, who provides healthcare services, and any healthcare
facility, as defined in § 27-20-1, including any mental health and/or substance abuse treatment
facility, physician, or other licensed practitioner identified to the review agent as having primary
responsibility for the care, treatment, and services rendered to a patient.
     (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 are 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 healthcare provider's claims that results in the recoupment or set-off
of funds previously paid to the healthcare provider in respect to such claims shall be completed no
later than eighteen (18) months after the completed claims were initially paid, except that the period
for recoupment or set-off for claims submitted by a mental health and/or substance use disorder
provider, for those services, licensed by this state, and participating with the health insurer or health
plan, shall be no later than twelve (12) months. This section shall not restrict any review, audit, or
investigation regarding claims that are submitted fraudulently; are known, or should have been
known, by the healthcare provider to be a pattern of inappropriate billing according to the standards
for provider billing of their respective medical or dental specialties; 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 healthcare provider shall seek reimbursement from a payer for underpayment of a
claim later than 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, "healthcare provider" means an individual clinician,
either in practice independently or in a group, who provides healthcare services, and any healthcare
facility, as defined in § 27-41-2, including any mental health and/or substance abuse treatment
facility, physician, or other licensed practitioner identified to the review agent as having primary
responsibility for the care, treatment, and services rendered to a patient.
     (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 are prescribed herein.
     SECTION 5. This act shall take effect upon passage.
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LC004478/SUB A
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