Rhode Island 2025 Regular Session

Rhode Island House Bill H5561 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2
3	3
4	4
5	5	2025 -- H 5561
6	6	========
7	7	LC001604
8	8	========
9	9	S T A T E O F R H O D E I S L A N D
10	10	IN GENERAL ASSEMBLY
11	11	JANUARY SESSION, A.D. 2025
12	12	____________
13	13
14	14	A N A C T
15	15	RELATING TO BUSINESSES AND PROFESSIONS -- BOARD OF MEDICAL LICENSURE
16	16	AND DISCIPLINE
17	17	Introduced By: Representative Arthur J. Corvese
18	18	Date Introduced: February 26, 2025
19	19	Referred To: House Corporations
20	20
21	21
22	22	It is enacted by the General Assembly as follows:
23	23	SECTION 1. Section 5-37-5.1 of the General Laws in Chapter 5-37 entitled "Board of 1
24	24	Medical Licensure and Discipline" is hereby amended to read as follows: 2
25	25	5-37-5.1. Unprofessional conduct. 3
26	26	The term “unprofessional conduct” as used in this chapter includes, but is not limited to, 4
27	27	the following items or any combination of these items and may be further defined by regulations 5
28	28	established by the board with the prior approval of the director: 6
29	29	(1) Fraudulent or deceptive procuring or use of a license or limited registration; 7
30	30	(2) All advertising of medical business that is intended or has a tendency to deceive the 8
31	31	public; 9
32	32	(3) Conviction of a felony; conviction of a crime arising out of the practice of medicine; 10
33	33	(4) Abandoning a patient; 11
34	34	(5) Dependence upon controlled substances, habitual drunkenness, or rendering 12
35	35	professional services to a patient while the physician or limited registrant is intoxicated or 13
36	36	incapacitated by the use of drugs; 14
37	37	(6) Promotion by a physician or limited registrant of the sale of drugs, devices, appliances, 15
38	38	or goods or services provided for a patient in a manner as to exploit the patient for the financial 16
39	39	gain of the physician or limited registrant; 17
40	40	(7) Immoral conduct of a physician or limited registrant in the practice of medicine; 18
41	41
42	42
43	43	LC001604 - Page 2 of 14
44	44	(8) Willfully making and filing false reports or records in the practice of medicine; 1
45	45	(9) Willfully omitting to file or record, or willfully impeding or obstructing a filing or 2
46	46	recording, or inducing another person to omit to file or record, medical or other reports as required 3
47	47	by law; 4
48	48	(10) Failing to furnish details of a patient’s medical record to succeeding physicians, 5
49	49	healthcare facility, or other healthcare providers upon proper request pursuant to § 5-37.3-4; 6
50	50	(11) Soliciting professional patronage by agents or persons or profiting from acts of those 7
51	51	representing themselves to be agents of the licensed physician or limited registrants; 8
52	52	(12) Dividing fees or agreeing to split or divide the fees received for professional services 9
53	53	for any person for bringing to or referring a patient; 10
54	54	(13) Agreeing with clinical or bioanalytical laboratories to accept payments from these 11
55	55	laboratories for individual tests or test series for patients; 12
56	56	(14) Making willful misrepresentations in treatments; 13
57	57	(15) Practicing medicine with an unlicensed physician except in an accredited 14
58	58	preceptorship or residency training program, or aiding or abetting unlicensed persons in the practice 15
59	59	of medicine; 16
60	60	(16) Gross and willful overcharging for professional services; including filing of false 17
61	61	statements for collection of fees for which services are not rendered, or willfully making or assisting 18
62	62	in making a false claim or deceptive claim or misrepresenting a material fact for use in determining 19
63	63	rights to health care or other benefits; 20
64	64	(17) Offering, undertaking, or agreeing to cure or treat disease by a secret method, 21
65	65	procedure, treatment, or medicine; 22
66	66	(18) Professional or mental incompetency; 23
67	67	(19) Incompetent, negligent, or willful misconduct in the practice of medicine, which 24
68	68	includes the rendering of medically unnecessary services, and any departure from, or the failure to 25
69	69	conform to, the minimal standards of acceptable and prevailing medical practice in his or her area 26
70	70	of expertise as is determined by the board. The board does not need to establish actual injury to the 27
71	71	patient in order to adjudge a physician or limited registrant guilty of the unacceptable medical 28
72	72	practice in this subsection; 29
73	73	(20) Failing to comply with the provisions of chapter 4.7 of title 23; 30
74	74	(21) Surrender, revocation, suspension, limitation of privilege based on quality of care 31
75	75	provided, or any other disciplinary action against a license or authorization to practice medicine in 32
76	76	another state or jurisdiction; or surrender, revocation, suspension, or any other disciplinary action 33
77	77	relating to a membership on any medical staff or in any medical or professional association or 34
78	78
79	79
80	80	LC001604 - Page 3 of 14
81	81	society while under disciplinary investigation by any of those authorities or bodies for acts or 1
82	82	conduct similar to acts or conduct that would constitute grounds for action as described in this 2
83	83	chapter; 3
84	84	(22) Multiple adverse judgments, settlements, or awards arising from medical liability 4
85	85	claims related to acts or conduct that would constitute grounds for action as described in this 5
86	86	chapter; 6
87	87	(23) Failing to furnish the board, its chief administrative officer, investigator, or 7
88	88	representatives, information legally requested by the board; 8
89	89	(24) Violating any provision or provisions of this chapter or the rules and regulations of 9
90	90	the board or any rules or regulations promulgated by the director or of an action, stipulation, or 10
91	91	agreement of the board; 11
92	92	(25) Cheating on or attempting to subvert the licensing examination; 12
93	93	(26) Violating any state or federal law or regulation relating to controlled substances; 13
94	94	(27) Failing to maintain standards established by peer-review boards, including, but not 14
95	95	limited to: standards related to proper utilization of services, use of nonaccepted procedure, and/or 15
96	96	quality of care; 16
97	97	(28) A pattern of medical malpractice, or willful or gross malpractice on a particular 17
98	98	occasion; 18
99	99	(29) Agreeing to treat a beneficiary of health insurance under title XVIII of the Social 19
100	100	Security Act, 42 U.S.C. § 1395 et seq., “Medicare Act,” and then charging or collecting from this 20
101	101	beneficiary any amount in excess of the amount or amounts permitted pursuant to the Medicare 21
102	102	Act; 22
103	103	(30) Sexual contact between a physician and patient during the existence of the 23
104	104	physician/patient relationship; 24
105	105	(31) Knowingly violating the provisions of § 23-4.13-2(d); or 25
106	106	(32) Performing a pelvic examination or supervising a pelvic examination performed by 26
107	107	an individual practicing under the supervision of a physician on an anesthetized or unconscious 27
108	108	female patient without first obtaining the patient’s informed consent to pelvic examination, unless 28
109	109	the performance of a pelvic examination is within the scope of the surgical procedure or diagnostic 29
110	110	examination to be performed on the patient for which informed consent has otherwise been 30
111	111	obtained or in the case of an unconscious patient, the pelvic examination is required for diagnostic 31
112	112	purposes and is medically necessary. 32
113	113	(33) Failing to submit medical bills to a health insurer, based solely on the reason that the 33
114	114	bill may arise from third-party claim or incident, other than a workers' compensation claim pursuant 34
115	115
116	116
117	117	LC001604 - Page 4 of 14
118	118	to chapter 33 of title 28. 1
119	119	SECTION 2. Section 27-18-61 of the General Laws in Chapter 27-18 entitled "Accident 2
120	120	and Sickness Insurance Policies" is hereby amended to read as follows: 3
121	121	27-18-61. Prompt processing of claims. 4
122	122	(a)(1) A health care entity or health plan operating in the state shall pay all complete claims 5
123	123	for covered health care services submitted to the health care entity or health plan by a health care 6
124	124	provider or by a policyholder within forty (40) calendar days following the date of receipt of a 7
125	125	complete written claim or within thirty (30) calendar days following the date of receipt of a 8
126	126	complete electronic claim. Each health plan shall establish a written standard defining what 9
127	127	constitutes a complete claim and shall distribute this standard to all participating providers. 10
128	128	(2) No health care entity or health plan shall deny a claim for payment of any medical bill, 11
129	129	based solely on the reason that the bill may have arisen from a third-party claim or incident, other 12
130	130	than a workers' compensation claim pursuant to chapter 33 of title 28. 13
131	131	(b) If the health care entity or health plan denies or pends a claim, the health care entity or 14
132	132	health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing the 15
133	133	health care provider or policyholder of any and all reasons for denying or pending the claim and 16
134	134	what, if any, additional information is required to process the claim. No health care entity or health 17
135	135	plan may limit the time period in which additional information may be submitted to complete a 18
136	136	claim. 19
137	137	(c) Any claim that is resubmitted by a health care provider or policyholder shall be treated 20
138	138	by the health care entity or health plan pursuant to the provisions of subsection (a) of this section. 21
139	139	(d) A health care entity or health plan which fails to reimburse the health care provider or 22
140	140	policyholder after receipt by the health care entity or health plan of a complete claim within the 23
141	141	required timeframes shall pay to the health care provider or the policyholder who submitted the 24
142	142	claim, in addition to any reimbursement for health care services provided, interest which shall 25
143	143	accrue at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day 26
144	144	after receipt of a complete electronic claim or on the forty-first (41st) day after receipt of a complete 27
145	145	written claim, and ending on the date the payment is issued to the health care provider or the 28
146	146	policyholder. 29
147	147	(e) Exceptions to the requirements of this section are as follows: 30
148	148	(1) No health care entity or health plan operating in the state shall be in violation of this 31
149	149	section for a claim submitted by a health care provider or policyholder if: 32
150	150	(i) Failure to comply is caused by a directive from a court or federal or state agency; 33
151	151	(ii) The health care entity or health plan is in liquidation or rehabilitation or is operating in 34
152	152
153	153
154	154	LC001604 - Page 5 of 14
155	155	compliance with a court-ordered plan of rehabilitation; or 1
156	156	(iii) The health care entity or health plan’s compliance is rendered impossible due to 2
157	157	matters beyond its control that are not caused by it. 3
158	158	(2) No health care entity or health plan operating in the state shall be in violation of this 4
159	159	section for any claim: (i) initially submitted more than ninety (90) days after the service is rendered, 5
160	160	or (ii) resubmitted more than ninety (90) days after the date the health care provider received the 6
161	161	notice provided for in subsection (b) of this section; provided, this exception shall not apply in the 7
162	162	event compliance is rendered impossible due to matters beyond the control of the health care 8
163	163	provider and were not caused by the health care provider. 9
164	164	(3) No health care entity or health plan operating in the state shall be in violation of this 10
165	165	section while the claim is pending due to a fraud investigation by a state or federal agency. 11
166	166	(4) No health care entity or health plan operating in the state shall be obligated under this 12
167	167	section to pay interest to any health care provider or policyholder for any claim if the director of 13
168	168	business regulation finds that the entity or plan is in substantial compliance with this section. A 14
169	169	health care entity or health plan seeking such a finding from the director shall submit any 15
170	170	documentation that the director shall require. A health care entity or health plan which is found to 16
171	171	be in substantial compliance with this section shall thereafter submit any documentation that the 17
172	172	director may require on an annual basis for the director to assess ongoing compliance with this 18
173	173	section. 19
174	174	(5) A health care entity or health plan may petition the director for a waiver of the provision 20
175	175	of this section for a period not to exceed ninety (90) days in the event the health care entity or health 21
176	176	plan is converting or substantially modifying its claims processing systems. 22
177	177	(f) For purposes of this section, the following definitions apply: 23
178	178	(1) “Claim” means: (i) a bill or invoice for covered services; (ii) a line item of service; or 24
179	179	(iii) all services for one patient or subscriber within a bill or invoice. 25
180	180	(2) “Date of receipt” means the date the health care entity or health plan receives the claim 26
181	181	whether via electronic submission or as a paper claim. 27
182	182	(3) “Health care entity” means a licensed insurance company or nonprofit hospital or 28
183	183	medical or dental service corporation or plan or health maintenance organization, or a contractor 29
184	184	as described in § 23-17.13-2(2) [repealed], which operates a health plan. 30
185	185	(4) “Health care provider” means an individual clinician, either in practice independently 31
186	186	or in a group, who provides health care services, and otherwise referred to as a non-institutional 32
187	187	provider. 33
188	188	(5) “Health care services” include, but are not limited to, medical, mental health, substance 34
189	189
190	190
191	191	LC001604 - Page 6 of 14
192	192	abuse, dental and any other services covered under the terms of the specific health plan. 1
193	193	(6) “Health plan” means a plan operated by a health care entity that provides for the 2
194	194	delivery of health care services to persons enrolled in those plans through: 3
195	195	(i) Arrangements with selected providers to furnish health care services; and/or 4
196	196	(ii) Financial incentive for persons enrolled in the plan to use the participating providers 5
197	197	and procedures provided for by the health plan. 6
198	198	(7) “Policyholder” means a person covered under a health plan or a representative 7
199	199	designated by that person. 8
200	200	(8) “Substantial compliance” means that the health care entity or health plan is processing 9
201	201	and paying ninety-five percent (95%) or more of all claims within the time frame provided for in 10
202	202	subsections (a) and (b) of this section. 11
203	203	(g) Any provision in a contract between a health care entity or a health plan and a health 12
204	204	care provider which is inconsistent with this section shall be void and of no force and effect. 13
205	205	SECTION 3. Section 27-19-52 of the General Laws in Chapter 27-19 entitled "Nonprofit 14
206	206	Hospital Service Corporations" is hereby amended to read as follows: 15
207	207	27-19-52. Prompt processing of claims. 16
208	208	(a)(1) A healthcare entity or health plan operating in the state shall pay all complete claims 17
209	209	for covered healthcare services submitted to the healthcare entity or health plan by a healthcare 18
210	210	provider or by a policyholder within forty (40) calendar days following the date of receipt of a 19
211	211	complete written claim or within thirty (30) calendar days following the date of receipt of a 20
212	212	complete electronic claim. Each health plan shall establish a written standard defining what 21
213	213	constitutes a complete claim and shall distribute this standard to all participating providers. 22
214	214	(2) No health care entity or health plan shall deny a claim for payment of any medical bill, 23
215	215	based solely on the reason that the bill may have arisen from a third-party claim or incident, other 24
216	216	than a workers' compensation claim pursuant to chapter 33 of title 28. 25
217	217	(b) If the healthcare entity or health plan denies or pends a claim, the healthcare entity or 26
218	218	health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing the 27
219	219	healthcare provider or policyholder of any and all reasons for denying or pending the claim and 28
220	220	what, if any, additional information is required to process the claim. No healthcare entity or health 29
221	221	plan may limit the time period in which additional information may be submitted to complete a 30
222	222	claim. 31
223	223	(c) Any claim that is resubmitted by a healthcare provider or policyholder shall be treated 32
224	224	by the healthcare entity or health plan pursuant to the provisions of subsection (a) of this section. 33
225	225	(d) A healthcare entity or health plan that fails to reimburse the healthcare provider or 34
226	226
227	227
228	228	LC001604 - Page 7 of 14
229	229	policyholder after receipt by the healthcare entity or health plan of a complete claim within the 1
230	230	required timeframes shall pay to the healthcare provider or the policyholder who submitted the 2
231	231	claim, in addition to any reimbursement for healthcare services provided, interest that shall accrue 3
232	232	at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day after receipt 4
233	233	of a complete electronic claim or on the forty-first (41st) day after receipt of a complete written 5
234	234	claim, and ending on the date the payment is issued to the healthcare provider or the policyholder. 6
235	235	(e) Exceptions to the requirements of this section are as follows: 7
236	236	(1) No healthcare entity or health plan operating in the state shall be in violation of this 8
237	237	section for a claim submitted by a healthcare provider or policyholder if: 9
238	238	(i) Failure to comply is caused by a directive from a court or federal or state agency; 10
239	239	(ii) The healthcare provider or health plan is in liquidation or rehabilitation or is operating 11
240	240	in compliance with a court-ordered plan of rehabilitation; or 12
241	241	(iii) The healthcare entity or health plan’s compliance is rendered impossible due to matters 13
242	242	beyond its control that are not caused by it. 14
243	243	(2) No healthcare entity or health plan operating in the state shall be in violation of this 15
244	244	section for any claim: (i) Initially submitted more than ninety (90) days after the service is rendered, 16
245	245	or (ii) Resubmitted more than ninety (90) days after the date the healthcare provider received the 17
246	246	notice provided for in § 27-18-61(b); provided, this exception shall not apply in the event 18
247	247	compliance is rendered impossible due to matters beyond the control of the healthcare provider and 19
248	248	were not caused by the healthcare provider. 20
249	249	(3) No healthcare entity or health plan operating in the state shall be in violation of this 21
250	250	section while the claim is pending due to a fraud investigation by a state or federal agency. 22
251	251	(4) No healthcare entity or health plan operating in the state shall be obligated under this 23
252	252	section to pay interest to any healthcare provider or policyholder for any claim if the director of the 24
253	253	department of business regulation finds that the entity or plan is in substantial compliance with this 25
254	254	section. A healthcare entity or health plan seeking such a finding from the director shall submit any 26
255	255	documentation that the director shall require. A healthcare entity or health plan that is found to be 27
256	256	in substantial compliance with this section shall after this submit any documentation that the 28
257	257	director may require on an annual basis for the director to assess ongoing compliance with this 29
258	258	section. 30
259	259	(5) A healthcare entity or health plan may petition the director for a waiver of the provision 31
260	260	of this section for a period not to exceed ninety (90) days in the event the healthcare entity or health 32
261	261	plan is converting or substantially modifying its claims processing systems. 33
262	262	(f) For purposes of this section, the following definitions apply: 34
263	263
264	264
265	265	LC001604 - Page 8 of 14
266	266	(1) “Claim” means: 1
267	267	(i) A bill or invoice for covered services; 2
268	268	(ii) A line item of service; or 3
269	269	(iii) All services for one patient or subscriber within a bill or invoice. 4
270	270	(2) “Date of receipt” means the date the healthcare entity or health plan receives the claim 5
271	271	whether via electronic submission or has a paper claim. 6
272	272	(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or 7
273	273	medical or dental service corporation or plan or health maintenance organization, or a contractor 8
274	274	as described in § 23-17.13-2(2), that operates a health plan. 9
275	275	(4) “Healthcare provider” means an individual clinician, either in practice independently 10
276	276	or in a group, who provides healthcare services, and referred to as a non-institutional provider. 11
277	277	(5) “Healthcare services” include, but are not limited to, medical, mental health, substance 12
278	278	abuse, dental, and any other services covered under the terms of the specific health plan. 13
279	279	(6) “Health plan” means a plan operated by a healthcare entity that provides for the delivery 14
280	280	of healthcare services to persons enrolled in those plans through: 15
281	281	(i) Arrangements with selected providers to furnish healthcare services; and/or 16
282	282	(ii) Financial incentive for persons enrolled in the plan to use the participating providers 17
283	283	and procedures provided for by the health plan. 18
284	284	(7) “Policyholder” means a person covered under a health plan or a representative 19
285	285	designated by that person. 20
286	286	(8) “Substantial compliance” means that the healthcare entity or health plan is processing 21
287	287	and paying ninety-five percent (95%) or more of all claims within the time frame provided for in § 22
288	288	27-18-61(a) and (b). 23
289	289	(g) Any provision in a contract between a healthcare entity or a health plan and a healthcare 24
290	290	provider that is inconsistent with this section shall be void and of no force and effect. 25
291	291	SECTION 4. Section 27-20-47 of the General Laws in Chapter 27-20 entitled "Nonprofit 26
292	292	Medical Service Corporations" is hereby amended to read as follows: 27
293	293	27-20-47. Prompt processing of claims. 28
294	294	(a)(1) A healthcare entity or health plan operating in the state shall pay all complete claims 29
295	295	for covered healthcare services submitted to the healthcare entity or health plan by a healthcare 30
296	296	provider or by a policyholder within forty (40) calendar days following the date of receipt of a 31
297	297	complete written claim or within thirty (30) calendar days following the date of receipt of a 32
298	298	complete electronic claim. Each health plan shall establish a written standard defining what 33
299	299	constitutes a complete claim and shall distribute the standard to all participating providers. 34
300	300
301	301
302	302	LC001604 - Page 9 of 14
303	303	(2) No health care entity or health plan shall deny a claim for payment of any medical bill, 1
304	304	based solely on the reason that the bill may have arisen from a third-party claim or incident, other 2
305	305	than a workers' compensation claim pursuant to chapter 33 of title 28. 3
306	306	(b) If the healthcare entity or health plan denies or pends a claim, the healthcare entity or 4
307	307	health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing the 5
308	308	healthcare provider or policyholder of any and all reasons for denying or pending the claim and 6
309	309	what, if any, additional information is required to process the claim. No healthcare entity or health 7
310	310	plan may limit the time period in which additional information may be submitted to complete a 8
311	311	claim. 9
312	312	(c) Any claim that is resubmitted by a healthcare provider or policyholder shall be treated 10
313	313	by the healthcare entity or health plan pursuant to the provisions of subsection (a) of this section. 11
314	314	(d) A healthcare entity or health plan which fails to reimburse the healthcare provider or 12
315	315	policyholder after receipt by the healthcare entity or health plan of a complete claim within the 13
316	316	required timeframes shall pay to the healthcare provider or the policyholder who submitted the 14
317	317	claim, in addition to any reimbursement for healthcare services provided, interest that shall accrue 15
318	318	at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day after receipt 16
319	319	of a complete electronic claim or on the forty-first (41st) day after receipt of a complete written 17
320	320	claim, and ending on the date the payment is issued to the healthcare provider or the policyholder. 18
321	321	(e) Exceptions to the requirements of this section are as follows: 19
322	322	(1) No healthcare entity or health plan operating in the state shall be in violation of this 20
323	323	section for a claim submitted by a healthcare provider or policyholder if: 21
324	324	(i) Failure to comply is caused by a directive from a court or federal or state agency; 22
325	325	(ii) The healthcare entity or health plan is in liquidation or rehabilitation or is operating in 23
326	326	compliance with a court-ordered plan of rehabilitation; or 24
327	327	(iii) The healthcare entity or health plan’s compliance is rendered impossible due to matters 25
328	328	beyond its control that are not caused by it. 26
329	329	(2) No healthcare entity or health plan operating in the state shall be in violation of this 27
330	330	section for any claim: (i) Initially submitted more than ninety (90) days after the service is rendered, 28
331	331	or (ii) Resubmitted more than ninety (90) days after the date the healthcare provider received the 29
332	332	notice provided for in § 27-18-61(b); provided, this exception shall not apply in the event 30
333	333	compliance is rendered impossible due to matters beyond the control of the healthcare provider and 31
334	334	were not caused by the healthcare provider. 32
335	335	(3) No healthcare entity or health plan operating in the state shall be in violation of this 33
336	336	section while the claim is pending due to a fraud investigation by a state or federal agency. 34
337	337
338	338
339	339	LC001604 - Page 10 of 14
340	340	(4) No healthcare entity or health plan operating in the state shall be obligated under this 1
341	341	section to pay interest to any healthcare provider or policyholder for any claim if the director of the 2
342	342	department of business regulation finds that the entity or plan is in substantial compliance with this 3
343	343	section. A healthcare entity or health plan seeking such a finding from the director shall submit any 4
344	344	documentation that the director shall require. A healthcare entity or health plan that is found to be 5
345	345	in substantial compliance with this section shall after this submit any documentation that the 6
346	346	director may require on an annual basis for the director to assess ongoing compliance with this 7
347	347	section. 8
348	348	(5) A healthcare entity or health plan may petition the director for a waiver of the provision 9
349	349	of this section for a period not to exceed ninety (90) days in the event the healthcare entity or health 10
350	350	plan is converting or substantially modifying its claims processing systems. 11
351	351	(f) For purposes of this section, the following definitions apply: 12
352	352	(1) “Claim” means: (i) A bill or invoice for covered services; (ii) A line item of service; or 13
353	353	(iii) All services for one patient or subscriber within a bill or invoice. 14
354	354	(2) “Date of receipt” means the date the healthcare entity or health plan receives the claim 15
355	355	whether via electronic submission or has a paper claim. 16
356	356	(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or 17
357	357	medical or dental service corporation or plan or health maintenance organization, or a contractor 18
358	358	as described in § 23-17.13-2(2), that operates a health plan. 19
359	359	(4) “Healthcare provider” means an individual clinician, either in practice independently 20
360	360	or in a group, who provides healthcare services, and referred to as a non-institutional provider. 21
361	361	(5) “Healthcare services” include, but are not limited to, medical, mental health, substance 22
362	362	abuse, dental, and any other services covered under the terms of the specific health plan. 23
363	363	(6) “Health plan” means a plan operated by a healthcare entity that provides for the delivery 24
364	364	of healthcare services to persons enrolled in the plan through: 25
365	365	(i) Arrangements with selected providers to furnish healthcare services; and/or 26
366	366	(ii) Financial incentive for persons enrolled in the plan to use the participating providers 27
367	367	and procedures provided for by the health plan. 28
368	368	(7) “Policyholder” means a person covered under a health plan or a representative 29
369	369	designated by that person. 30
370	370	(8) “Substantial compliance” means that the healthcare entity or health plan is processing 31
371	371	and paying ninety-five percent (95%) or more of all claims within the time frame provided for in § 32
372	372	27-18-61(a) and (b). 33
373	373	(g) Any provision in a contract between a healthcare entity or a health plan and a healthcare 34
374	374
375	375
376	376	LC001604 - Page 11 of 14
377	377	provider that is inconsistent with this section shall be void and of no force and effect. 1
378	378	SECTION 5. Section 27-41-64 of the General Laws in Chapter 27-41 entitled "Health 2
379	379	Maintenance Organizations" is hereby amended to read as follows: 3
380	380	27-41-64. Prompt processing of claims. 4
381	381	(a)(1) A healthcare entity or health plan operating in the state shall pay all complete claims 5
382	382	for covered healthcare services submitted to the healthcare entity or health plan by a healthcare 6
383	383	provider or by a policyholder within forty (40) calendar days following the date of receipt of a 7
384	384	complete written claim or within thirty (30) calendar days following the date of receipt of a 8
385	385	complete electronic claim. Each health plan shall establish a written standard defining what 9
386	386	constitutes a complete claim and shall distribute this standard to all participating providers. 10
387	387	(2) No health care entity or health plan shall deny a claim for payment of any medical bill, 11
388	388	based solely on the reason that the bill may have arisen from a third-party claim or incident, other 12
389	389	than a workers' compensation claim pursuant to chapter 33 of title 28. 13
390	390	(b) If the healthcare entity or health plan denies or pends a claim, the healthcare entity or 14
391	391	health plan shall have thirty (30) calendar days from receipt of the claim to notify in writing the 15
392	392	healthcare provider or policyholder of any and all reasons for denying or pending the claim and 16
393	393	what, if any, additional information is required to process the claim. No healthcare entity or health 17
394	394	plan may limit the time period in which additional information may be submitted to complete a 18
395	395	claim. 19
396	396	(c) Any claim that is resubmitted by a healthcare provider or policyholder shall be treated 20
397	397	by the healthcare entity or health plan pursuant to the provisions of subsection (a) of this section. 21
398	398	(d) A healthcare entity or health plan that fails to reimburse the healthcare provider or 22
399	399	policyholder after receipt by the healthcare entity or health plan of a complete claim within the 23
400	400	required timeframes shall pay to the healthcare provider or the policyholder who submitted the 24
401	401	claim, in addition to any reimbursement for healthcare services provided, interest that shall accrue 25
402	402	at the rate of twelve percent (12%) per annum commencing on the thirty-first (31st) day after receipt 26
403	403	of a complete electronic claim or on the forty-first (41st) day after receipt of a complete written 27
404	404	claim, and ending on the date the payment is issued to the healthcare provider or the policyholder. 28
405	405	(e) Exceptions to the requirements of this section are as follows: 29
406	406	(1) No healthcare entity or health plan operating in the state shall be in violation of this 30
407	407	section for a claim submitted by a healthcare provider or policyholder if: 31
408	408	(i) Failure to comply is caused by a directive from a court or federal or state agency; 32
409	409	(ii) The healthcare entity or health plan is in liquidation or rehabilitation or is operating in 33
410	410	compliance with a court-ordered plan of rehabilitation; or 34
411	411
412	412
413	413	LC001604 - Page 12 of 14
414	414	(iii) The healthcare entity or health plan’s compliance is rendered impossible due to matters 1
415	415	beyond its control that are not caused by it. 2
416	416	(2) No healthcare entity or health plan operating in the state shall be in violation of this 3
417	417	section for any claim: (i) Initially submitted more than ninety (90) days after the service is rendered, 4
418	418	or (ii) Resubmitted more than ninety (90) days after the date the healthcare provider received the 5
419	419	notice provided for in § 27-18-61(b); provided, this exception shall not apply in the event 6
420	420	compliance is rendered impossible due to matters beyond the control of the healthcare provider and 7
421	421	were not caused by the healthcare provider. 8
422	422	(3) No healthcare entity or health plan operating in the state shall be in violation of this 9
423	423	section while the claim is pending due to a fraud investigation by a state or federal agency. 10
424	424	(4) No healthcare entity or health plan operating in the state shall be obligated under this 11
425	425	section to pay interest to any healthcare provider or policyholder for any claim if the director of the 12
426	426	department of business regulation finds that the entity or plan is in substantial compliance with this 13
427	427	section. A healthcare entity or health plan seeking that finding from the director shall submit any 14
428	428	documentation that the director shall require. A healthcare entity or health plan that is found to be 15
429	429	in substantial compliance with this section shall submit any documentation the director may require 16
430	430	on an annual basis for the director to assess ongoing compliance with this section. 17
431	431	(5) A healthcare entity or health plan may petition the director for a waiver of the provision 18
432	432	of this section for a period not to exceed ninety (90) days in the event the healthcare entity or health 19
433	433	plan is converting or substantially modifying its claims processing systems. 20
434	434	(f) For purposes of this section, the following definitions apply: 21
435	435	(1) “Claim” means: (i) A bill or invoice for covered services; (ii) A line item of service; or 22
436	436	(iii) All services for one patient or subscriber within a bill or invoice. 23
437	437	(2) “Date of receipt” means the date the healthcare entity or health plan receives the claim 24
438	438	whether via electronic submission or as a paper claim. 25
439	439	(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or 26
440	440	medical or dental service corporation or plan or health maintenance organization, or a contractor 27
441	441	as described in § 23-17.13-2(2) [repealed] that operates a health plan. 28
442	442	(4) “Healthcare provider” means an individual clinician, either in practice independently 29
443	443	or in a group, who provides healthcare services, and is referred to as a non-institutional provider. 30
444	444	(5) “Healthcare services” include, but are not limited to, medical, mental health, substance 31
445	445	abuse, dental, and any other services covered under the terms of the specific health plan. 32
446	446	(6) “Health plan” means a plan operated by a healthcare entity that provides for the delivery 33
447	447	of healthcare services to persons enrolled in the plan through: 34
448	448
449	449
450	450	LC001604 - Page 13 of 14
451	451	(i) Arrangements with selected providers to furnish healthcare services; and/or 1
452	452	(ii) Financial incentive for persons enrolled in the plan to use the participating providers 2
453	453	and procedures provided for by the health plan. 3
454	454	(7) “Policyholder” means a person covered under a health plan or a representative 4
455	455	designated by that person. 5
456	456	(8) “Substantial compliance” means that the healthcare entity or health plan is processing 6
457	457	and paying ninety-five percent (95%) or more of all claims within the time frame provided for in § 7
458	458	27-18-61(a) and (b). 8
459	459	(g) Any provision in a contract between a healthcare entity or a health plan and a healthcare 9
460	460	provider that is inconsistent with this section shall be void and of no force and effect. 10
461	461	SECTION 6. This act shall take effect upon passage. 11
462	462	========
463	463	LC001604
464	464	========
465	465
466	466
467	467	LC001604 - Page 14 of 14
468	468	EXPLANATION
469	469	BY THE LEGISLATIVE COUNCIL
470	470	OF
471	471	A N A C T
472	472	RELATING TO BUSINESSES AND PROFESSIONS -- BOARD OF MEDICAL LICENSURE
473	473	AND DISCIPLINE
474	474	***
475	475	This act would prohibit healthcare providers and health plans from denying the payment 1
476	476	of a medical bill, solely because the bill may have arisen from a third-party claim. 2
477	477	This act would take effect upon passage. 3
478	478	========
479	479	LC001604
480	480	========