Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.6 - Benefit Determination General Requirements

Current through June 14, 2024
A. Each
				  review agent must submit to the Office its policies and procedures in
				  accordance with the Act that evidence adherence to the following:
1. In order to initiate a claim the claimant
				  must have stated the claimant's name, specific medical condition or symptom and
				  specific treatment, service, or product and submits such information to the
				  proper claim processing unit;
2. In
				  the event of a failure by a claimant to follow the health care entity's claims
				  procedures for a pre-service claim, the health care entity or its review agent
				  must comply with notification provisions in accordance with R.I. Gen. Laws
				  §
											27-18.9-5(a) and
				  this Part.
a. For non-urgent and non-emergent
				  pre-service claims:
(1) Notify claimant in
				  writing of this failure as soon as possible and no later than five (5) calendar
				  days following such failure; and
(2) This notification must also inform
				  claimant of the specific claims procedures not complied with as well as the
				  proper procedures to file a pre-service claim.
b. Notwithstanding the above, if the
				  pre-service claim relates to urgent or emergent health care services:
(1) The health care entity or its review
				  agent must notify and inform claimant of the specific procedural failure and
				  proper procedures to file a pre-service claim within twenty-four (24) hours
				  following the failure; and
(2)
				  Notification may be oral, unless written notification is requested by the
				  claimant.
3. In
				  accordance with R.I. Gen. Laws §
											27-18.9-4(a)(1),
				  beneficiaries and providers shall be provided with a summary of its benefit
				  determination review programs and adverse benefit determination criteria in a
				  manner acceptable to the Commissioner that includes a summary of the standards,
				  procedures, and methods to be used in evaluating proposed, concurrent, or
				  delivered health care services;
4.
				  In accordance with R.I. Gen. Laws §
											27-18.9-4(a)(5),
				  the requirement that no employee of, or other individual rendering or
				  recommending an adverse benefit determination or appeal decision on behalf of
				  the review agent or health care entity may receive any financial or other
				  incentives based upon the number of denials of certification made by that
				  employee or individual;
5. In
				  accordance with R.I. Gen. Laws §
											27-18.9-4(a)(6),
				  the review agent has not entered into an understanding, a compensation
				  agreement or a contract with its employees or agents whereby the compensation
				  of its employees or its agents is based, directly or indirectly, upon a
				  reduction of health care services or the charges for those services, a
				  reduction of lengths of stays, or the use of alternative treatment
				  settings;
6. An adverse benefit
				  determination and internal appeals process consistent with R.I. Gen. Laws
				  §
											27-18.9-4(a)(7)
				  and acceptable to the Office, whereby beneficiaries, authorized
				  representatives, their physicians, or other health care service providers may
				  seek prompt reconsideration or appeal of adverse benefit determinations by the
				  review agent according to all state and federal requirements;
7. In accordance with R.I. Gen. Laws §
											27-18.9-4(a)(8),
				  the health care entity or its relevant review agent has a mechanism to provide
				  the claimant with a description of its claims procedures and any procedures for
				  obtaining approvals as a prerequisite for obtaining a benefit or coverage for
				  such benefit. This description should, at a minimum, be placed in the summary
				  of benefits document and be available on the review agent's or the relevant
				  health care entity's website and upon request from the claimant; and
8. All administrative benefit determination
				  decisions and notifications shall be made within a reasonable period of time,
				  considering circumstances, acceptable to the Commissioner. For utilization
				  review determinations and notifications refer to §§
											14.6(B) and (E)   of
				  this Part.