Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.4 - Prompt Processing of Claims

Current through June 14, 2024
A. Payment of
				  Claims-Timeframes, Interest and Exceptions
1.
				  A subject entity shall pay all complete claims for health care services
				  submitted to the subject entity by a Rhode Island health care provider or by a
				  Rhode Island policyholder within forty calendar days following the date of
				  receipt of a complete written claim or within thirty calendar days following
				  the date of receipt of a complete electronic claim. When computing the periods
				  of time required for payment of each complete claim by this Part, the date of
				  receipt of the claim shall not be included in the computation of time. The last
				  day of the period so computed shall be included, unless it is a Saturday, a
				  Sunday, or a legal holiday, then the next business day shall be included. As
				  used in this Part, "legal holiday" includes New Year's Day, Martin Luther King,
				  Jr. Day, Memorial Day, Independence Day, Victory Day, Labor Day, Columbus Day,
				  Veterans Day, Thanksgiving Day, and Christmas Day.
a. Example 1 - A Rhode Island physician
				  submits a complete written claim by mail to a subject entity on May 1st. The
				  subject entity operates a health plan in Rhode Island and the health plan is
				  certified by OHIC. The subject entity receives the claim on May 3rd. June 12th
				  is forty days from May 3rd. The subject entity has until June 12th to pay the
				  claim. For the purposes of the examples contained in this Part, we assume that
				  none of the processing deadlines falls on a Saturday, Sunday or legal
				  holiday.
b. Example 2 - A Rhode
				  Island physician submits a complete electronic claim to a subject entity on May
				  1st. The subject entity operates a health plan in Rhode Island and the health
				  plan is certified by OHIC. The subject entity receives the claim on May 1st.
				  May 31st is thirty days from May 1st. The subject entity has until May 31st to
				  pay the claim.
c. Example 3 - A
				  Rhode Island physician submits a complete electronic claim to a Rhode Island
				  nonprofit hospital and medical service corporation on May 1st. The claim is
				  received on May 1st. The nonprofit hospital and medical service corporation is
				  a member of the national Blue Cross Blue Shield Association. The claim was
				  submitted for services provided in Rhode Island and the physician who provided
				  the health care services is a participating provider in the plans operated by
				  the nonprofit hospital and medical service corporation. The patient is not
				  insured by the Rhode Island nonprofit hospital and medical service corporation,
				  but instead is insured by an out-of-state Blue Cross Blue Shield Association
				  member. As a member of the national Blue Cross Blue Shield Association, the
				  Rhode Island nonprofit hospital and medical service corporation processes the
				  claim for the insured and makes payment to the physician. This claim is subject
				  to this Part because the claim was submitted by a Rhode Island physician to a
				  subject entity. May 31st is thirty days from May 1st. The Rhode Island
				  nonprofit hospital and medical service corporation has until May 31st to pay
				  the claim.
d. Example 4 - A
				  Massachusetts physician submits an electronic claim to a Rhode Island insurer
				  that operates a health plan in Massachusetts. The health care services were
				  provided to a Massachusetts resident in Massachusetts. This claim is not
				  subject to this Part because the claim was not submitted by a Rhode Island
				  health care provider or by a Rhode Island policyholder.
e. Example 5 - A Rhode Island physician
				  submits an electronic claim to a Massachusetts insurer that operates a health
				  plan in Rhode Island. The health care services were provided in Rhode Island
				  and the physician is a participating provider in the Rhode Island health plan
				  operated by the Massachusetts insurer. This claim is subject to this Part
				  because (i) the claim was submitted by a Rhode Island physician who is a
				  participating provider in the Massachusetts insurer's Rhode Island plan and
				  (ii) was submitted to a subject entity. The Massachusetts insurer is a subject
				  entity because it operates a health plan in this state.
f. Example 6 - A Rhode Island physician
				  submits an electronic claim to a Massachusetts insurer that operates a health
				  plan in Rhode Island. The health care services were provided in Rhode Island,
				  but the physician is not a participating provider in the Rhode Island health
				  plan operated by the Massachusetts insurer. The health care services were not
				  provided within the plan and the claim is an out-of-network claim. This claim
				  is not subject to this Part. The Massachusetts insurer is a subject entity
				  because operates a health plan in this state. Thus, it must process all Rhode
				  Island claims it receives within the timeframes set out in this
				  regulation.
g. Example 7 - An
				  out-of-state physician submits an electronic claim for services provided
				  outside of Rhode Island to a contractor operating in Rhode Island. This claim
				  is not subject to this Part because the claim was not submitted by a Rhode
				  Island health care provider or by a Rhode Island policyholder.
h. Example 8 - A Rhode Island physician
				  submits an electronic claim to a Rhode Island-licensed insurer. The claim is
				  processed by the insurer but is paid using the funds of a self-insured entity.
				  This claim is subject to this Part because the claim was:
(1) submitted by a Rhode Island health care
				  provider, and
(2) was submitted to
				  a subject entity.
i.
				  Example 9 - A Rhode Island physician submits an electronic claim to a Rhode
				  Island- contractor. The claim is processed by the contractor but is paid using
				  the funds of a self-insured entity. This claim is subject to this regulation
				  because the claim was:
(1) submitted by a
				  Rhode Island physician, and
(2)
				  was submitted to a subject entity.
j. Example 10 - A Rhode Island dentist
				  submits a complete written claim by mail to a Rhode Island nonprofit dental
				  service corporation on May 1st. The nonprofit dental service corporation
				  receives the claim on May 3rd. June 12th is forty days from May 3rd. The
				  nonprofit dental service corporation has until June 12th to pay the
				  claim.
k. Example 11 - A Rhode
				  Island dentist submits a complete written claim by mail to a subject entity on
				  May 1st. The subject entity operates a health plan in Rhode Island, the health
				  plan is certified by OHIC and the health plan provides dental coverage. The
				  subject entity receives the claim on May 3rd. June 12th is forty days from May
				  3rd. The subject entity has until June 12th to pay the claim.
l. Example 12 - A Rhode Island dentist
				  submits a complete electronic claim to a subject entity on May 1st. The subject
				  entity operates a health plan in Rhode Island, the health plan is certified by
				  OHIC and the health plan provides dental coverage. The subject entity receives
				  the claim on May 1st. May 31st is thirty days from May 1st. The subject entity
				  has until May 31st to pay the claim.
m. Example 13 - A Rhode Island mental health
				  provider submits a complete electronic claim to a subject entity on May 1st.
				  The subject entity operates a health plan in Rhode Island and the health plan
				  is certified by OHIC. The subject entity receives the claim on May 1st and
				  forwards the claim to an out of state contractor for processing. May 31st is
				  thirty days from May 1st. The subject entity is responsible for payment of the
				  claim and has until May 31st to ensure that the claim is paid.
n. Example 14 - A Rhode Island mental health
				  provider submits a complete electronic claim directly to an out of state entity
				  for processing on May 1st. The out of state entity processes the claim on
				  behalf of or for a subject entity operating in Rhode Island. The out of state
				  entity receives the claim on May 1st. May 31st is thirty days from May 1st. The
				  subject entity is responsible for payment of the claim and has until May 31st
				  to ensure that the claim is paid.