2025 -- H 5561
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LC001604
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S T A T E O F R H O D E I S L A N D
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2025
____________
A N A C T
RELATING TO BUSINESSES AND PROFESSIONS -- BOARD OF MEDICAL LICENSURE
AND DISCIPLINE
Introduced By: Representative Arthur J. Corvese
Date Introduced: February 26, 2025
Referred To: House Corporations
It is enacted by the General Assembly as follows:
SECTION 1. Section 5-37-5.1 of the General Laws in Chapter 5-37 entitled "Board of 1
Medical Licensure and Discipline" is hereby amended to read as follows: 2
5-37-5.1. Unprofessional conduct. 3
The term “unprofessional conduct” as used in this chapter includes, but is not limited to, 4
the following items or any combination of these items and may be further defined by regulations 5
established by the board with the prior approval of the director: 6
(1) Fraudulent or deceptive procuring or use of a license or limited registration; 7
(2) All advertising of medical business that is intended or has a tendency to deceive the 8
public; 9
(3) Conviction of a felony; conviction of a crime arising out of the practice of medicine; 10
(4) Abandoning a patient; 11
(5) Dependence upon controlled substances, habitual drunkenness, or rendering 12
professional services to a patient while the physician or limited registrant is intoxicated or 13
incapacitated by the use of drugs; 14
(6) Promotion by a physician or limited registrant of the sale of drugs, devices, appliances, 15
or goods or services provided for a patient in a manner as to exploit the patient for the financial 16
gain of the physician or limited registrant; 17
(7) Immoral conduct of a physician or limited registrant in the practice of medicine; 18
LC001604 - Page 2 of 14
(8) Willfully making and filing false reports or records in the practice of medicine; 1
(9) Willfully omitting to file or record, or willfully impeding or obstructing a filing or 2
recording, or inducing another person to omit to file or record, medical or other reports as required 3
by law; 4
(10) Failing to furnish details of a patient’s medical record to succeeding physicians, 5
healthcare facility, or other healthcare providers upon proper request pursuant to § 5-37.3-4; 6
(11) Soliciting professional patronage by agents or persons or profiting from acts of those 7
representing themselves to be agents of the licensed physician or limited registrants; 8
(12) Dividing fees or agreeing to split or divide the fees received for professional services 9
for any person for bringing to or referring a patient; 10
(13) Agreeing with clinical or bioanalytical laboratories to accept payments from these 11
laboratories for individual tests or test series for patients; 12
(14) Making willful misrepresentations in treatments; 13
(15) Practicing medicine with an unlicensed physician except in an accredited 14
preceptorship or residency training program, or aiding or abetting unlicensed persons in the practice 15
of medicine; 16
(16) Gross and willful overcharging for professional services; including filing of false 17
statements for collection of fees for which services are not rendered, or willfully making or assisting 18
in making a false claim or deceptive claim or misrepresenting a material fact for use in determining 19
rights to health care or other benefits; 20
(17) Offering, undertaking, or agreeing to cure or treat disease by a secret method, 21
procedure, treatment, or medicine; 22
(18) Professional or mental incompetency; 23
(19) Incompetent, negligent, or willful misconduct in the practice of medicine, which 24
includes the rendering of medically unnecessary services, and any departure from, or the failure to 25
conform to, the minimal standards of acceptable and prevailing medical practice in his or her area 26
of expertise as is determined by the board. The board does not need to establish actual injury to the 27
patient in order to adjudge a physician or limited registrant guilty of the unacceptable medical 28
practice in this subsection; 29
(20) Failing to comply with the provisions of chapter 4.7 of title 23; 30
(21) Surrender, revocation, suspension, limitation of privilege based on quality of care 31
provided, or any other disciplinary action against a license or authorization to practice medicine in 32
another state or jurisdiction; or surrender, revocation, suspension, or any other disciplinary action 33
relating to a membership on any medical staff or in any medical or professional association or 34
LC001604 - Page 3 of 14
society while under disciplinary investigation by any of those authorities or bodies for acts or 1
conduct similar to acts or conduct that would constitute grounds for action as described in this 2
chapter; 3
(22) Multiple adverse judgments, settlements, or awards arising from medical liability 4
claims related to acts or conduct that would constitute grounds for action as described in this 5
chapter; 6
(23) Failing to furnish the board, its chief administrative officer, investigator, or 7
representatives, information legally requested by the board; 8
(24) Violating any provision or provisions of this chapter or the rules and regulations of 9
the board or any rules or regulations promulgated by the director or of an action, stipulation, or 10
agreement of the board; 11
(25) Cheating on or attempting to subvert the licensing examination; 12
(26) Violating any state or federal law or regulation relating to controlled substances; 13
(27) Failing to maintain standards established by peer-review boards, including, but not 14
limited to: standards related to proper utilization of services, use of nonaccepted procedure, and/or 15
quality of care; 16
(28) A pattern of medical malpractice, or willful or gross malpractice on a particular 17
occasion; 18
(29) Agreeing to treat a beneficiary of health insurance under title XVIII of the Social 19
Security Act, 42 U.S.C. § 1395 et seq., “Medicare Act,” and then charging or collecting from this 20
beneficiary any amount in excess of the amount or amounts permitted pursuant to the Medicare 21
Act; 22
(30) Sexual contact between a physician and patient during the existence of the 23
physician/patient relationship; 24
(31) Knowingly violating the provisions of § 23-4.13-2(d); or 25
(32) Performing a pelvic examination or supervising a pelvic examination performed by 26
an individual practicing under the supervision of a physician on an anesthetized or unconscious 27
female patient without first obtaining the patient’s informed consent to pelvic examination, unless 28
the performance of a pelvic examination is within the scope of the surgical procedure or diagnostic 29
examination to be performed on the patient for which informed consent has otherwise been 30
obtained or in the case of an unconscious patient, the pelvic examination is required for diagnostic 31
purposes and is medically necessary. 32
(33) Failing to submit medical bills to a health insurer, based solely on the reason that the 33
bill may arise from third-party claim or incident, other than a workers' compensation claim pursuant 34
LC001604 - Page 4 of 14
to chapter 33 of title 28. 1
SECTION 2. Section 27-18-61 of the General Laws in Chapter 27-18 entitled "Accident 2
and Sickness Insurance Policies" is hereby amended to read as follows: 3
27-18-61. Prompt processing of claims. 4
(a)(1) A health care entity or health plan operating in the state shall pay all complete claims 5
for covered health care services submitted to the health care entity or health plan by a health care 6
provider or by a policyholder within forty (40) calendar days following the date of receipt of a 7
complete written claim or within thirty (30) calendar days following the date of receipt of a 8
complete electronic claim. Each health plan shall establish a written standard defining what 9
constitutes a complete claim and shall distribute this standard to all participating providers. 10
(2) No health care entity or health plan shall deny a claim for payment of any medical bill, 11
based solely on the reason that the bill may have arisen from a third-party claim or incident, other 12
than a workers' compensation claim pursuant to chapter 33 of title 28. 13
(b) If the health care entity or health plan denies or pends a claim, the health care entity or 14
health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing the 15
health care provider or policyholder of any and all reasons for denying or pending the claim and 16
what, if any, additional information is required to process the claim. No health care entity or health 17
plan may limit the time period in which additional information may be submitted to complete a 18
claim. 19
(c) Any claim that is resubmitted by a health care provider or policyholder shall be treated 20
by the health care entity or health plan pursuant to the provisions of subsection (a) of this section. 21
(d) A health care entity or health plan which fails to reimburse the health care provider or 22
policyholder after receipt by the health care entity or health plan of a complete claim within the 23
required timeframes shall pay to the health care provider or the policyholder who submitted the 24
claim, in addition to any reimbursement for health care services provided, interest which shall 25
accrue at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day 26
after receipt of a complete electronic claim or on the forty-first (41st) day after receipt of a complete 27
written claim, and ending on the date the payment is issued to the health care provider or the 28
policyholder. 29
(e) Exceptions to the requirements of this section are as follows: 30
(1) No health care entity or health plan operating in the state shall be in violation of this 31
section for a claim submitted by a health care provider or policyholder if: 32
(i) Failure to comply is caused by a directive from a court or federal or state agency; 33
(ii) The health care entity or health plan is in liquidation or rehabilitation or is operating in 34
LC001604 - Page 5 of 14
compliance with a court-ordered plan of rehabilitation; or 1
(iii) The health care entity or health plan’s compliance is rendered impossible due to 2
matters beyond its control that are not caused by it. 3
(2) No health care entity or health plan operating in the state shall be in violation of this 4
section for any claim: (i) initially submitted more than ninety (90) days after the service is rendered, 5
or (ii) resubmitted more than ninety (90) days after the date the health care provider received the 6
notice provided for in subsection (b) of this section; provided, this exception shall not apply in the 7
event compliance is rendered impossible due to matters beyond the control of the health care 8
provider and were not caused by the health care provider. 9
(3) No health care entity or health plan operating in the state shall be in violation of this 10
section while the claim is pending due to a fraud investigation by a state or federal agency. 11
(4) No health care entity or health plan operating in the state shall be obligated under this 12
section to pay interest to any health care provider or policyholder for any claim if the director of 13
business regulation finds that the entity or plan is in substantial compliance with this section. A 14
health care entity or health plan seeking such a finding from the director shall submit any 15
documentation that the director shall require. A health care entity or health plan which is found to 16
be in substantial compliance with this section shall thereafter submit any documentation that the 17
director may require on an annual basis for the director to assess ongoing compliance with this 18
section. 19
(5) A health care entity or health plan may petition the director for a waiver of the provision 20
of this section for a period not to exceed ninety (90) days in the event the health care entity or health 21
plan is converting or substantially modifying its claims processing systems. 22
(f) For purposes of this section, the following definitions apply: 23
(1) “Claim” means: (i) a bill or invoice for covered services; (ii) a line item of service; or 24
(iii) all services for one patient or subscriber within a bill or invoice. 25
(2) “Date of receipt” means the date the health care entity or health plan receives the claim 26
whether via electronic submission or as a paper claim. 27
(3) “Health care entity” means a licensed insurance company or nonprofit hospital or 28
medical or dental service corporation or plan or health maintenance organization, or a contractor 29
as described in § 23-17.13-2(2) [repealed], which operates a health plan. 30
(4) “Health care provider” means an individual clinician, either in practice independently 31
or in a group, who provides health care services, and otherwise referred to as a non-institutional 32
provider. 33
(5) “Health care services” include, but are not limited to, medical, mental health, substance 34
LC001604 - Page 6 of 14
abuse, dental and any other services covered under the terms of the specific health plan. 1
(6) “Health plan” means a plan operated by a health care entity that provides for the 2
delivery of health care services to persons enrolled in those plans through: 3
(i) Arrangements with selected providers to furnish health care services; and/or 4
(ii) Financial incentive for persons enrolled in the plan to use the participating providers 5
and procedures provided for by the health plan. 6
(7) “Policyholder” means a person covered under a health plan or a representative 7
designated by that person. 8
(8) “Substantial compliance” means that the health care entity or health plan is processing 9
and paying ninety-five percent (95%) or more of all claims within the time frame provided for in 10
subsections (a) and (b) of this section. 11
(g) Any provision in a contract between a health care entity or a health plan and a health 12
care provider which is inconsistent with this section shall be void and of no force and effect. 13
SECTION 3. Section 27-19-52 of the General Laws in Chapter 27-19 entitled "Nonprofit 14
Hospital Service Corporations" is hereby amended to read as follows: 15
27-19-52. Prompt processing of claims. 16
(a)(1) A healthcare entity or health plan operating in the state shall pay all complete claims 17
for covered healthcare services submitted to the healthcare entity or health plan by a healthcare 18
provider or by a policyholder within forty (40) calendar days following the date of receipt of a 19
complete written claim or within thirty (30) calendar days following the date of receipt of a 20
complete electronic claim. Each health plan shall establish a written standard defining what 21
constitutes a complete claim and shall distribute this standard to all participating providers. 22
(2) No health care entity or health plan shall deny a claim for payment of any medical bill, 23
based solely on the reason that the bill may have arisen from a third-party claim or incident, other 24
than a workers' compensation claim pursuant to chapter 33 of title 28. 25
(b) If the healthcare entity or health plan denies or pends a claim, the healthcare entity or 26
health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing the 27
healthcare provider or policyholder of any and all reasons for denying or pending the claim and 28
what, if any, additional information is required to process the claim. No healthcare entity or health 29
plan may limit the time period in which additional information may be submitted to complete a 30
claim. 31
(c) Any claim that is resubmitted by a healthcare provider or policyholder shall be treated 32
by the healthcare entity or health plan pursuant to the provisions of subsection (a) of this section. 33
(d) A healthcare entity or health plan that fails to reimburse the healthcare provider or 34
LC001604 - Page 7 of 14
policyholder after receipt by the healthcare entity or health plan of a complete claim within the 1
required timeframes shall pay to the healthcare provider or the policyholder who submitted the 2
claim, in addition to any reimbursement for healthcare services provided, interest that shall accrue 3
at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day after receipt 4
of a complete electronic claim or on the forty-first (41st) day after receipt of a complete written 5
claim, and ending on the date the payment is issued to the healthcare provider or the policyholder. 6
(e) Exceptions to the requirements of this section are as follows: 7
(1) No healthcare entity or health plan operating in the state shall be in violation of this 8
section for a claim submitted by a healthcare provider or policyholder if: 9
(i) Failure to comply is caused by a directive from a court or federal or state agency; 10
(ii) The healthcare provider or health plan is in liquidation or rehabilitation or is operating 11
in compliance with a court-ordered plan of rehabilitation; or 12
(iii) The healthcare entity or health plan’s compliance is rendered impossible due to matters 13
beyond its control that are not caused by it. 14
(2) No healthcare entity or health plan operating in the state shall be in violation of this 15
section for any claim: (i) Initially submitted more than ninety (90) days after the service is rendered, 16
or (ii) Resubmitted more than ninety (90) days after the date the healthcare provider received the 17
notice provided for in § 27-18-61(b); provided, this exception shall not apply in the event 18
compliance is rendered impossible due to matters beyond the control of the healthcare provider and 19
were not caused by the healthcare provider. 20
(3) No healthcare entity or health plan operating in the state shall be in violation of this 21
section while the claim is pending due to a fraud investigation by a state or federal agency. 22
(4) No healthcare entity or health plan operating in the state shall be obligated under this 23
section to pay interest to any healthcare provider or policyholder for any claim if the director of the 24
department of business regulation finds that the entity or plan is in substantial compliance with this 25
section. A healthcare entity or health plan seeking such a finding from the director shall submit any 26
documentation that the director shall require. A healthcare entity or health plan that is found to be 27
in substantial compliance with this section shall after this submit any documentation that the 28
director may require on an annual basis for the director to assess ongoing compliance with this 29
section. 30
(5) A healthcare entity or health plan may petition the director for a waiver of the provision 31
of this section for a period not to exceed ninety (90) days in the event the healthcare entity or health 32
plan is converting or substantially modifying its claims processing systems. 33
(f) For purposes of this section, the following definitions apply: 34
LC001604 - Page 8 of 14
(1) “Claim” means: 1
(i) A bill or invoice for covered services; 2
(ii) A line item of service; or 3
(iii) All services for one patient or subscriber within a bill or invoice. 4
(2) “Date of receipt” means the date the healthcare entity or health plan receives the claim 5
whether via electronic submission or has a paper claim. 6
(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or 7
medical or dental service corporation or plan or health maintenance organization, or a contractor 8
as described in § 23-17.13-2(2), that operates a health plan. 9
(4) “Healthcare provider” means an individual clinician, either in practice independently 10
or in a group, who provides healthcare services, and referred to as a non-institutional provider. 11
(5) “Healthcare services” include, but are not limited to, medical, mental health, substance 12
abuse, dental, and any other services covered under the terms of the specific health plan. 13
(6) “Health plan” means a plan operated by a healthcare entity that provides for the delivery 14
of healthcare services to persons enrolled in those plans through: 15
(i) Arrangements with selected providers to furnish healthcare services; and/or 16
(ii) Financial incentive for persons enrolled in the plan to use the participating providers 17
and procedures provided for by the health plan. 18
(7) “Policyholder” means a person covered under a health plan or a representative 19
designated by that person. 20
(8) “Substantial compliance” means that the healthcare entity or health plan is processing 21
and paying ninety-five percent (95%) or more of all claims within the time frame provided for in § 22
27-18-61(a) and (b). 23
(g) Any provision in a contract between a healthcare entity or a health plan and a healthcare 24
provider that is inconsistent with this section shall be void and of no force and effect. 25
SECTION 4. Section 27-20-47 of the General Laws in Chapter 27-20 entitled "Nonprofit 26
Medical Service Corporations" is hereby amended to read as follows: 27
27-20-47. Prompt processing of claims. 28
(a)(1) A healthcare entity or health plan operating in the state shall pay all complete claims 29
for covered healthcare services submitted to the healthcare entity or health plan by a healthcare 30
provider or by a policyholder within forty (40) calendar days following the date of receipt of a 31
complete written claim or within thirty (30) calendar days following the date of receipt of a 32
complete electronic claim. Each health plan shall establish a written standard defining what 33
constitutes a complete claim and shall distribute the standard to all participating providers. 34
LC001604 - Page 9 of 14
(2) No health care entity or health plan shall deny a claim for payment of any medical bill, 1
based solely on the reason that the bill may have arisen from a third-party claim or incident, other 2
than a workers' compensation claim pursuant to chapter 33 of title 28. 3
(b) If the healthcare entity or health plan denies or pends a claim, the healthcare entity or 4
health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing the 5
healthcare provider or policyholder of any and all reasons for denying or pending the claim and 6
what, if any, additional information is required to process the claim. No healthcare entity or health 7
plan may limit the time period in which additional information may be submitted to complete a 8
claim. 9
(c) Any claim that is resubmitted by a healthcare provider or policyholder shall be treated 10
by the healthcare entity or health plan pursuant to the provisions of subsection (a) of this section. 11
(d) A healthcare entity or health plan which fails to reimburse the healthcare provider or 12
policyholder after receipt by the healthcare entity or health plan of a complete claim within the 13
required timeframes shall pay to the healthcare provider or the policyholder who submitted the 14
claim, in addition to any reimbursement for healthcare services provided, interest that shall accrue 15
at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day after receipt 16
of a complete electronic claim or on the forty-first (41st) day after receipt of a complete written 17
claim, and ending on the date the payment is issued to the healthcare provider or the policyholder. 18
(e) Exceptions to the requirements of this section are as follows: 19
(1) No healthcare entity or health plan operating in the state shall be in violation of this 20
section for a claim submitted by a healthcare provider or policyholder if: 21
(i) Failure to comply is caused by a directive from a court or federal or state agency; 22
(ii) The healthcare entity or health plan is in liquidation or rehabilitation or is operating in 23
compliance with a court-ordered plan of rehabilitation; or 24
(iii) The healthcare entity or health plan’s compliance is rendered impossible due to matters 25
beyond its control that are not caused by it. 26
(2) No healthcare entity or health plan operating in the state shall be in violation of this 27
section for any claim: (i) Initially submitted more than ninety (90) days after the service is rendered, 28
or (ii) Resubmitted more than ninety (90) days after the date the healthcare provider received the 29
notice provided for in § 27-18-61(b); provided, this exception shall not apply in the event 30
compliance is rendered impossible due to matters beyond the control of the healthcare provider and 31
were not caused by the healthcare provider. 32
(3) No healthcare entity or health plan operating in the state shall be in violation of this 33
section while the claim is pending due to a fraud investigation by a state or federal agency. 34
LC001604 - Page 10 of 14
(4) No healthcare entity or health plan operating in the state shall be obligated under this 1
section to pay interest to any healthcare provider or policyholder for any claim if the director of the 2
department of business regulation finds that the entity or plan is in substantial compliance with this 3
section. A healthcare entity or health plan seeking such a finding from the director shall submit any 4
documentation that the director shall require. A healthcare entity or health plan that is found to be 5
in substantial compliance with this section shall after this submit any documentation that the 6
director may require on an annual basis for the director to assess ongoing compliance with this 7
section. 8
(5) A healthcare entity or health plan may petition the director for a waiver of the provision 9
of this section for a period not to exceed ninety (90) days in the event the healthcare entity or health 10
plan is converting or substantially modifying its claims processing systems. 11
(f) For purposes of this section, the following definitions apply: 12
(1) “Claim” means: (i) A bill or invoice for covered services; (ii) A line item of service; or 13
(iii) All services for one patient or subscriber within a bill or invoice. 14
(2) “Date of receipt” means the date the healthcare entity or health plan receives the claim 15
whether via electronic submission or has a paper claim. 16
(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or 17
medical or dental service corporation or plan or health maintenance organization, or a contractor 18
as described in § 23-17.13-2(2), that operates a health plan. 19
(4) “Healthcare provider” means an individual clinician, either in practice independently 20
or in a group, who provides healthcare services, and referred to as a non-institutional provider. 21
(5) “Healthcare services” include, but are not limited to, medical, mental health, substance 22
abuse, dental, and any other services covered under the terms of the specific health plan. 23
(6) “Health plan” means a plan operated by a healthcare entity that provides for the delivery 24
of healthcare services to persons enrolled in the plan through: 25
(i) Arrangements with selected providers to furnish healthcare services; and/or 26
(ii) Financial incentive for persons enrolled in the plan to use the participating providers 27
and procedures provided for by the health plan. 28
(7) “Policyholder” means a person covered under a health plan or a representative 29
designated by that person. 30
(8) “Substantial compliance” means that the healthcare entity or health plan is processing 31
and paying ninety-five percent (95%) or more of all claims within the time frame provided for in § 32
27-18-61(a) and (b). 33
(g) Any provision in a contract between a healthcare entity or a health plan and a healthcare 34
LC001604 - Page 11 of 14
provider that is inconsistent with this section shall be void and of no force and effect. 1
SECTION 5. Section 27-41-64 of the General Laws in Chapter 27-41 entitled "Health 2
Maintenance Organizations" is hereby amended to read as follows: 3
27-41-64. Prompt processing of claims. 4
(a)(1) A healthcare entity or health plan operating in the state shall pay all complete claims 5
for covered healthcare services submitted to the healthcare entity or health plan by a healthcare 6
provider or by a policyholder within forty (40) calendar days following the date of receipt of a 7
complete written claim or within thirty (30) calendar days following the date of receipt of a 8
complete electronic claim. Each health plan shall establish a written standard defining what 9
constitutes a complete claim and shall distribute this standard to all participating providers. 10
(2) No health care entity or health plan shall deny a claim for payment of any medical bill, 11
based solely on the reason that the bill may have arisen from a third-party claim or incident, other 12
than a workers' compensation claim pursuant to chapter 33 of title 28. 13
(b) If the healthcare entity or health plan denies or pends a claim, the healthcare entity or 14
health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing the 15
healthcare provider or policyholder of any and all reasons for denying or pending the claim and 16
what, if any, additional information is required to process the claim. No healthcare entity or health 17
plan may limit the time period in which additional information may be submitted to complete a 18
claim. 19
(c) Any claim that is resubmitted by a healthcare provider or policyholder shall be treated 20
by the healthcare entity or health plan pursuant to the provisions of subsection (a) of this section. 21
(d) A healthcare entity or health plan that fails to reimburse the healthcare provider or 22
policyholder after receipt by the healthcare entity or health plan of a complete claim within the 23
required timeframes shall pay to the healthcare provider or the policyholder who submitted the 24
claim, in addition to any reimbursement for healthcare services provided, interest that shall accrue 25
at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day after receipt 26
of a complete electronic claim or on the forty-first (41st) day after receipt of a complete written 27
claim, and ending on the date the payment is issued to the healthcare provider or the policyholder. 28
(e) Exceptions to the requirements of this section are as follows: 29
(1) No healthcare entity or health plan operating in the state shall be in violation of this 30
section for a claim submitted by a healthcare provider or policyholder if: 31
(i) Failure to comply is caused by a directive from a court or federal or state agency; 32
(ii) The healthcare entity or health plan is in liquidation or rehabilitation or is operating in 33
compliance with a court-ordered plan of rehabilitation; or 34
LC001604 - Page 12 of 14
(iii) The healthcare entity or health plan’s compliance is rendered impossible due to matters 1
beyond its control that are not caused by it. 2
(2) No healthcare entity or health plan operating in the state shall be in violation of this 3
section for any claim: (i) Initially submitted more than ninety (90) days after the service is rendered, 4
or (ii) Resubmitted more than ninety (90) days after the date the healthcare provider received the 5
notice provided for in § 27-18-61(b); provided, this exception shall not apply in the event 6
compliance is rendered impossible due to matters beyond the control of the healthcare provider and 7
were not caused by the healthcare provider. 8
(3) No healthcare entity or health plan operating in the state shall be in violation of this 9
section while the claim is pending due to a fraud investigation by a state or federal agency. 10
(4) No healthcare entity or health plan operating in the state shall be obligated under this 11
section to pay interest to any healthcare provider or policyholder for any claim if the director of the 12
department of business regulation finds that the entity or plan is in substantial compliance with this 13
section. A healthcare entity or health plan seeking that finding from the director shall submit any 14
documentation that the director shall require. A healthcare entity or health plan that is found to be 15
in substantial compliance with this section shall submit any documentation the director may require 16
on an annual basis for the director to assess ongoing compliance with this section. 17
(5) A healthcare entity or health plan may petition the director for a waiver of the provision 18
of this section for a period not to exceed ninety (90) days in the event the healthcare entity or health 19
plan is converting or substantially modifying its claims processing systems. 20
(f) For purposes of this section, the following definitions apply: 21
(1) “Claim” means: (i) A bill or invoice for covered services; (ii) A line item of service; or 22
(iii) All services for one patient or subscriber within a bill or invoice. 23
(2) “Date of receipt” means the date the healthcare entity or health plan receives the claim 24
whether via electronic submission or as a paper claim. 25
(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or 26
medical or dental service corporation or plan or health maintenance organization, or a contractor 27
as described in § 23-17.13-2(2) [repealed] that operates a health plan. 28
(4) “Healthcare provider” means an individual clinician, either in practice independently 29
or in a group, who provides healthcare services, and is referred to as a non-institutional provider. 30
(5) “Healthcare services” include, but are not limited to, medical, mental health, substance 31
abuse, dental, and any other services covered under the terms of the specific health plan. 32
(6) “Health plan” means a plan operated by a healthcare entity that provides for the delivery 33
of healthcare services to persons enrolled in the plan through: 34
LC001604 - Page 13 of 14
(i) Arrangements with selected providers to furnish healthcare services; and/or 1
(ii) Financial incentive for persons enrolled in the plan to use the participating providers 2
and procedures provided for by the health plan. 3
(7) “Policyholder” means a person covered under a health plan or a representative 4
designated by that person. 5
(8) “Substantial compliance” means that the healthcare entity or health plan is processing 6
and paying ninety-five percent (95%) or more of all claims within the time frame provided for in § 7
27-18-61(a) and (b). 8
(g) Any provision in a contract between a healthcare entity or a health plan and a healthcare 9
provider that is inconsistent with this section shall be void and of no force and effect. 10
SECTION 6. This act shall take effect upon passage. 11
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LC001604
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EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO BUSINESSES AND PROFESSIONS -- BOARD OF MEDICAL LICENSURE
AND DISCIPLINE
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This act would prohibit healthcare providers and health plans from denying the payment 1
of a medical bill, solely because the bill may have arisen from a third-party claim. 2
This act would take effect upon passage. 3
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LC001604
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