2026 -- H 8327

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LC006081

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2026

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A N   A C T

RELATING TO INSURANCE -- PRIMARY CARE ADMINISTRATIVE FAIRNESS ACT

     Introduced By: Representatives Hopkins, Cruz, J. Brien, Casimiro, Cotter, Boylan,
Shanley, Phillips, Lima, and Place

     Date Introduced: March 20, 2026

     Referred To: House Health & Human Services

     It is enacted by the General Assembly as follows:

     SECTION 1. Title 27 of the General Laws entitled "INSURANCE" is hereby amended by

adding thereto the following chapter:

CHAPTER 84

PRIMARY CARE ADMINISTRATIVE FAIRNESS ACT

     27-84-1. Short title.

     This chapter shall be known and may be cited as the "Primary Care Administrative Fairness

Act."

     27-84-2. Definitions.

     As used in this chapter, the following terms have the following meanings:

     (1) "Covered services" means health care services for which a payer provides

reimbursement under a participating provider agreement.

     (2) “ICD-10” means International Classification of Diseases, 10th revision.

     (3) "Payer" means any health insurer, health maintenance organization, managed care

organization, or Medicare Advantage plan doing business in this state.

     27-84-3. Prohibition on uncompensated referral coordination.

     No payer shall require a primary care provider to perform uncompensated referral

coordination services, including preparation of documentation, submission of prior authorizations,

communication with specialists or insurers, tracking of approvals, or transmission of materials.

     27-84-4. Payer obligations for referral coordination.

     A payer shall either:

     (1) Eliminate prior authorization requirements for all primary care initiated referrals; or

     (2) Reimburse the primary care practice at reasonable attributable costs for each referral

coordination service, paid separately and unbundled from evaluation and management payments or

capitated payments, including Medicare Advantage payments.

     27-84-5. Coverage based on any recognized ICD-10 code.

     If a laboratory service is covered under any ICD-10 code recognized by the payer, coverage

shall not be denied solely because of the specific diagnostic code submitted by the ordering

physician.

     27-84-6. Prohibition on resubmissions.

     A payer shall not require a physician or practice to resubmit a claim, modify a code, or

provide additional justification solely to satisfy the payer’s internal coding preferences when the

service is otherwise covered.

     27-84-7. Contract provisions void.

     Any contract provision that violates this chapter shall be void and unenforceable.

     27-84-8. Enforcement.

     The office of the health insurance commissioner shall enforce the provisions of this chapter

and shall:

     (1) Require payers to update participating provider agreements no later than January 1,

2027;

     (2) Review payer policies for compliance with this chapter;

     (3) Void any payer contract provisions that are inconsistent with the requirements of this

chapter; and

     (4) On and after January 1, 2028 publish an annual report on referral volumes,

reimbursements for referral coordination services, and laboratory claim denial rates.

     SECTION 2. This act shall take effect on January 1, 2027

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- PRIMARY CARE ADMINISTRATIVE FAIRNESS ACT

***

     This act would prohibit payers from requiring uncompensated referral coordination by

primary care providers, require either elimination of referral prior authorizations, and prevent

denial of lab coverage based solely on diagnostic coding differences.

     This act would take effect on January 1, 2027

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