Rhode Island § 27-41-69 - Health Maintenance Organizations

§ 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 that allow for different time frames than are prescribed herein.