(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 that 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 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 known, or should have been known, by the health care 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.

Terms Used In Rhode Island General Laws 27-18-65

  • Health care facility: means an institution providing health care services or a health care setting, including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings. See Rhode Island General Laws 27-18-1.1.
  • Health care services: means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease. See Rhode Island General Laws 27-18-1.1.
  • provider: means a health care professional or a health care facility. See Rhode Island General Laws 27-18-1.1.

(b) No health-care 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, “health care provider” means an individual clinician, either in practice independently or in a group, who provides health-care services, and any health-care 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 prescribed herein.

History of Section.
(P.L. 2006, ch. 86, § 1; P.L. 2006, ch. 97, § 1; P.L. 2013, ch. 251, § 1; P.L. 2013, ch. 395, § 1; P.L. 2014, ch. 201, § 1; P.L. 2014, ch. 214, § 1; P.L. 2017, ch. 368, § 1; P.L. 2017, ch. 375, § 1.)