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Rhode Island General Laws 27-18-8.2. Notice of disapproval

     

If within the waiting period the commissioner finds that a filing does not meet the requirements of this chapter, he or she shall send to the insurer which made the filing written notice of disapproval of the filing, specifying in the notice in what respects he or she finds that the filing fails to meet the requirements of this chapter, and stating that the filing is disapproved.

History of Section.
(P.L. 1988, ch. 564, § 2.)

Rhode Island General Laws 27-18.8-2. Definitions

     

As used in this chapter:

Terms Used In Rhode Island General Laws 27-18.8-2

  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Contract: A legal written agreement that becomes binding when signed.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Judgement: The official decision of a court finally determining the respective rights and claims of the parties to a suit.
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • person: extends to and includes co-partnerships and bodies corporate and politic. See Rhode Island General Laws 43-3-6.
  • Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.

(1) “Adverse benefit determination” means a decision not to authorize a health care service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization review agent to authorize a health care service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse determination if the review agent and provider are in agreement regarding the decision. Adverse benefit determinations include:

(i) “Administrative adverse benefit determinations,” meaning any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual’s eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and

(ii) “Non-administrative adverse benefit determinations,” meaning any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the health care entity’s formulary.

(2) “Appeal” or “internal appeal” means a subsequent review of an adverse benefit determination upon request by a claimant to include the beneficiary or provider to reconsider all or part of the original adverse benefit determination.

(3) “Authorized representative” means an individual acting on behalf of the beneficiary and shall include: the ordering provider; any individual to whom the beneficiary has given express written consent to act on his or her behalf; a person authorized by law to provide substituted consent for the beneficiary; and, when the beneficiary is unable to provide consent, a family member of the beneficiary.

(4) “Beneficiary” means a policy holder subscriber, enrollee, or other individual participating in a health benefit plan.

(5) “Benefit determination” means a decision to approve or deny a request to provide or make payment for a health care service.

(6) “Certificate” means a certificate granted by the commissioner to a health care entity meeting the requirements of this chapter.

(7) “Commissioner” means the commissioner of the office of the health insurance commissioner.

(8) “Complaint” means an oral or written expression of dissatisfaction by a beneficiary, authorized representative, or provider. The appeal of an adverse benefit determination is not considered a complaint.

(9) “Delegate” means a person or entity authorized pursuant to a delegation of authority or directly or re-delegation of authority, by a health care entity or network plan to perform one or more of the functions and responsibilities of a health care entity and/or network plan set forth in this chapter or regulations or guidance promulgated thereunder.

(10) “Emergency services” or “emergent services” means those resources provided in the event of the sudden onset of a medical, behavioral health, or other health condition that the absence of immediate medical attention could reasonably be expected, by a prudent layperson, to result in placing the patient’s health in serious jeopardy, serious impairment to bodily or mental functions, or serious dysfunction of any bodily organ or part.

(11) “Health benefit plan” or “health plan” means a policy, contract, certificate, or agreement entered into, offered, or issued by a health care entity to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.

(12) “Health care entity” means an insurance company licensed, or required to be licensed, by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing health insurance, accident and sickness insurance, health benefits, or health care services.

(13) “Health care services” means and includes, but is not limited to: an admission, diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care services, activities, or supplies that are covered by the beneficiary’s health benefit plan.

(14) “Most-favored-rate clause” means a provision in a provider contract whereby the rates or fees to be paid by a health care entity are fixed, established, or adjusted to be equal to or lower than the rates or fees paid to the provider by any other health care entity.

(15) “Network” means the group or groups of participating providers providing health care services under a network plan.

(16) “Network plan” means a health benefit plan or health plan that either requires a beneficiary to use, or creates incentives, including financial incentives, for a beneficiary to use the providers managed, owned, under contract with, or employed by the health care entity.

(17) “Office” means the office of the health insurance commissioner.

(18) “Professional provider” means an individual provider or health care professional licensed, accredited, or certified to perform specified health care services consistent with state law and who provides these health care services and is not part of a separate facility or institutional contract.

(19) “Provider” means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider, or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.

(20) “Tiered network” means a network that identifies and groups some or all types of providers into specific groups to which different provider reimbursement, beneficiary cost-sharing, or provider access requirements, or any combination thereof, apply for the same services.

History of Section.
(P.L. 2017, ch. 302, art. 5, § 4.)