2021 -- H 5902

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LC001439

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2021

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A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representatives Serpa, Fellela, Ackerman, and Phillips

     Date Introduced: February 24, 2021

     Referred To: House Corporations

     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:

     27-18-85. Prompt processing of Medicaid claims.

     (a) A health insurance carrier, health benefit plan offering group, individual insurance

coverage, health care entity or health plan operating in this state after January 1, 2022 shall pay all

complete claims for covered health care services submitted by a health care provider or by a

policyholder within fifteen (15) calendar days following the date of receipt of a complete written

claim or within fifteen (15) calendar days following the date of receipt of a complete electronic

claim. The executive office of health and human services (EOHHS) shall establish a written

standard defining what constitutes a complete claim and shall distribute this standard to all

participating providers within three (3) months of the effective date of this section.

     (b) If the claim is denied or pended, the health insurer, the health plan offering group,

individual insurance coverage, the health care entity or health plan shall have fifteen (15) calendar

days from receipt of the claim to notify, in writing, the health care provider or policyholder of any

and all reasons for denying or pending the claim and what, if any, additional information is required

to process the claim. No health care entity, health care insurer, or health plan may limit the time

period in which additional information may be submitted to complete a claim.

     (c) If denial of a claim results from an error on the part of the health care insurer, health

care entity or health plan, the health insurer, the health care entity or health plan shall have fifteen

(15) calendar days to notify, in writing, the health care provider or policyholder of any and all errors

that result in denial or pending of the claim and will reprocess the claim forward for payment in

fifteen (15) calendar days or interest will accrue at the rate of fifteen percent (15%) per annum

commencing on the sixteenth day and ending on the date the payment is issued to the health care

provider or policyholder.

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

by the health insurer, the health care entity or health plan pursuant to the provisions of subsection

(a) of this section.

     (e)(1) A health care insurer, a health care entity or health plan which fails to notify the

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

fails to reimburse the health care provider or policyholder after receipt by the health care insurer,

the health care entity or health plan of a complete claim within the required timeframes shall pay

to the health care provider or the policyholder who submitted the claim, in addition to any

reimbursement for health care services provided, interest which shall accrue at the rate of fifteen

percent (15%) per annum commencing on the sixteenth day after receipt of a complete electronic

claim or on the sixteenth day after receipt of a complete written claim, and ending on the date the

payment is issued to the health care provider.

     (2) A health care insurer, health care entity or health plan which fails to reimburse the

health care provider or policyholder after receipt by the health care insurer, the health care entity

or health plan of a complete claim within the required timeframes shall pay to the health care

provider licensed by the department of behavioral healthcare, development disabilities and

hospitals providing treatment to individuals with behavioral health care needs pursuant to §§ 40.1-

24-1, 40.1-8.5-1, and 40.1-1-13 or the policyholder who submitted the claim in addition to any

reimbursement for health care services provided, interest which shall accrue at the rate of twenty-

five percent (25%) per annum commencing on the sixteenth day after receipt of a complete

electronic claim or on the sixteenth day after receipt of a complete written claim, and ending on the

date the payment is issued to the health care provider or the policyholder.

     SECTION 2. Chapter 27-19 of the General Laws entitled "NonProfit Hospital Service

Corporations" is hereby amended by adding thereto the following section:

     27-19-77. Prompt processing of Medicaid claims.

     (a) A health insurance carrier, health benefit plan offering group, individual insurance

coverage, health care entity or health plan operating in this state after January 1, 2022 shall pay all

complete claims for covered health care services submitted by a health care provider or by a

policyholder within fifteen (15) calendar days following the date of receipt of a complete written

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claim or within fifteen (15) calendar days following the date of receipt of a complete electronic

claim. The executive office of health and human services (EOHHS) shall establish a written

standard defining what constitutes a complete claim and shall distribute this standard to all

participating providers within three (3) months of the effective date of this section.

     (b) If the claim is denied or pended, the health insurer, the health plan offering group,

individual insurance coverage, the health care entity or health plan shall have fifteen (15) calendar

days from receipt of the claim to notify, in writing, the health care provider or policyholder of any

and all reasons for denying or pending the claim and what, if any, additional information is required

to process the claim. No health care entity, health care insurer, or health plan may limit the time

period in which additional information may be submitted to complete a claim.

     (c) If denial of a claim results from an error on the part of the health care insurer, health

care entity or health plan, the health insurer, the health care entity or health plan shall have fifteen

(15) calendar days to notify, in writing, the health care provider or policyholder of any and all errors

that result in denial or pending of the claim and will reprocess the claim forward for payment in

fifteen (15) calendar days or interest will accrue at the rate of fifteen percent (15%) per annum

commencing on the sixteenth day and ending on the date the payment is issued to the health care

provider or policyholder.

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

by the health insurer, the health care entity or health plan pursuant to the provisions of subsection

(a) of this section.

     (e)(1) A health care insurer, a health care entity or health plan which fails to notify the

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

fails to reimburse the health care provider or policyholder after receipt by the health care insurer,

the health care entity or health plan of a complete claim within the required timeframes shall pay

to the health care provider or the policyholder who submitted the claim, in addition to any

reimbursement for health care services provided, interest which shall accrue at the rate of fifteen

percent (15%) per annum commencing on the sixteenth day after receipt of a complete electronic

claim or on the sixteenth day after receipt of a complete written claim, and ending on the date the

payment is issued to the health care provider.

     (2) A health care insurer, health care entity or health plan which fails to reimburse the

health care provider or policyholder after receipt by the health care insurer, the health care entity

or health plan of a complete claim within the required timeframes shall pay to the health care

provider licensed by the department of behavioral healthcare, development disabilities and

hospitals providing treatment to individuals with behavioral health care needs pursuant to §§ 40.1-

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24-1, 40.1-8.5-1, and 40.1-1-13 or the policyholder who submitted the claim in addition to any

reimbursement for health care services provided, interest which shall accrue at the rate of twenty-

five percent (25%) per annum commencing on the sixteenth day after receipt of a complete

electronic claim or on the sixteenth day after receipt of a complete written claim, and ending on the

date the payment is issued to the health care provider or the policyholder.

     SECTION 3. Chapter 27-20 of the General Laws entitled "NonProfit Medical Service

Corporations" is hereby amended by adding thereto the following section:

     27-20-73. Prompt processing of Medicaid claims.

     (a) A health insurance carrier, health benefit plan offering group, individual insurance

coverage, health care entity or health plan operating in this state after January 1, 2022 shall pay all

complete claims for covered health care services submitted by a health care provider or by a

policyholder within fifteen (15) calendar days following the date of receipt of a complete written

claim or within fifteen (15) calendar days following the date of receipt of a complete electronic

claim. The executive office of health and human services (EOHHS) shall establish a written

standard defining what constitutes a complete claim and shall distribute this standard to all

participating providers within three (3) months of the effective date of this section.

     (b) If the claim is denied or pended, the health insurer, the health plan offering group,

individual insurance coverage, the health care entity or health plan shall have fifteen (15) calendar

days from receipt of the claim to notify, in writing, the health care provider or policyholder of any

and all reasons for denying or pending the claim and what, if any, additional information is required

to process the claim. No health care entity, health care insurer, or health plan may limit the time

period in which additional information may be submitted to complete a claim.

     (c) If denial of a claim results from an error on the part of the health care insurer, health

care entity or health plan, the health insurer, the health care entity or health plan shall have fifteen

(15) calendar days to notify, in writing, the health care provider or policyholder of any and all errors

that result in denial or pending of the claim and will reprocess the claim forward for payment in

fifteen (15) calendar days or interest will accrue at the rate of fifteen percent (15%) per annum

commencing on the sixteenth day and ending on the date the payment is issued to the health care

provider or policyholder.

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

by the health insurer, the health care entity or health plan pursuant to the provisions of subsection

(a) of this section.

     (e) (1) A health care insurer, a health care entity or health plan which fails to notify the

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

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fails to reimburse the health care provider or policyholder after receipt by the health care insurer,

the health care entity or health plan of a complete claim within the required timeframes shall pay

to the health care provider or the policyholder who submitted the claim, in addition to any

reimbursement for health care services provided, interest which shall accrue at the rate of fifteen

percent (15%) per annum commencing on the sixteenth day after receipt of a complete electronic

claim or on the sixteenth day after receipt of a complete written claim, and ending on the date the

payment is issued to the health care provider.

     (2) A health care insurer, health care entity or health plan which fails to reimburse the

health care provider or policyholder after receipt by the health care insurer, the health care entity

or health plan of a complete claim within the required timeframes shall pay to the health care

provider licensed by the department of behavioral healthcare, development disabilities and

hospitals providing treatment to individuals with behavioral health care needs pursuant to §§ 40.1-

24-1, 40.1-8.5-1, and 40.1-1-13 or the policyholder who submitted the claim in addition to any

reimbursement for health care services provided, interest which shall accrue at the rate of twenty-

five percent (25%) per annum commencing on the sixteenth day after receipt of a complete

electronic claim or on the sixteenth day after receipt of a complete written claim, and ending on the

date the payment is issued to the health care provider or the policyholder.

     SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance

Organizations" is hereby amended by adding thereto the following section:

     27-41-90. Prompt processing of Medicaid claims.

     (a) A health insurance carrier, health benefit plan offering group, individual insurance

coverage, health care entity or health plan operating in this state after January 1, 2022 shall pay all

complete claims for covered health care services submitted by a health care provider or by a

policyholder within fifteen (15) calendar days following the date of receipt of a complete written

claim or within fifteen (15) calendar days following the date of receipt of a complete electronic

claim. The executive office of health and human services (EOHHS) shall establish a written

standard defining what constitutes a complete claim and shall distribute this standard to all

participating providers within three (3) months of the effective date of this section.

     (b) If the claim is denied or pended, the health insurer, the health plan offering group,

individual insurance coverage, the health care entity or health plan shall have fifteen (15) calendar

days from receipt of the claim to notify, in writing, the health care provider or policyholder of any

and all reasons for denying or pending the claim and what, if any, additional information is required

to process the claim. No health care entity, health care insurer, or health plan may limit the time

period in which additional information may be submitted to complete a claim.

LC001439 - Page 5 of 8

     (c) If denial of a claim results from an error on the part of the health care insurer, health

care entity or health plan, the health insurer, the health care entity or health plan shall have fifteen

(15) calendar days to notify, in writing, the health care provider or policyholder of any and all errors

that result in denial or pending of the claim and will reprocess the claim forward for payment in

fifteen (15) calendar days or interest will accrue at the rate of fifteen percent (15%) per annum

commencing on the sixteenth day and ending on the date the payment is issued to the health care

provider or policyholder.

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

by the health insurer, the health care entity or health plan pursuant to the provisions of subsection

(a) of this section.

     (e)(1) A health care insurer, a health care entity or health plan which fails to notify the

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

fails to reimburse the health care provider or policyholder after receipt by the health care insurer,

the health care entity or health plan of a complete claim within the required timeframes shall pay

to the health care provider or the policyholder who submitted the claim, in addition to any

reimbursement for health care services provided, interest which shall accrue at the rate of fifteen

percent (15%) per annum commencing on the sixteenth day after receipt of a complete electronic

claim or on the sixteenth day after receipt of a complete written claim, and ending on the date the

payment is issued to the health care provider.

     (2) A health care insurer, health care entity or health plan which fails to reimburse the

health care provider or policyholder after receipt by the health care insurer, the health care entity

or health plan of a complete claim within the required timeframes shall pay to the health care

provider licensed by the department of behavioral healthcare, development disabilities and

hospitals providing treatment to individuals with behavioral health care needs pursuant to §§ 40.1-

24-1, 40.1-8.5-1, and 40.1-1-13 or the policyholder who submitted the claim in addition to any

reimbursement for health care services provided, interest which shall accrue at the rate of twenty-

five percent (25%) per annum commencing on the sixteenth day after receipt of a complete

electronic claim or on the sixteenth day after receipt of a complete written claim, and ending on the

date the payment is issued to the health care provider or the policyholder.

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     SECTION 5. This act shall take effect upon passage.

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LC001439

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

***

     This act would require the prompt processing and payment of Medicaid claims for covered

health care services submitted by a health care provider or a policyholder within fifteen (15)

calendar days of receipt of a complete or electronic claim with a provision for the assessment of

interest for failure to notify health care providers or policyholders of denied or pending claims

commencing January 1, 2022.

     This act would take effect upon passage.

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LC001439

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