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-20-30-6.3 - Definitions

Current through June 14, 2024
A. As used in this Part:
1. "Affiliate" has the same meaning as set
				  out in the first sentence of R.I. Gen. Laws §
											27-35-1(a). An
				  "affiliate" of, or an entity or person "affiliated" with, a specific entity or
				  person, is an entity or person who directly or indirectly through one or more
				  intermediaries controls, or is controlled by, or is under common control with,
				  the entity or person specified.
2.
				  "Claim" means
a. a bill or invoice for
				  covered services,
b. a line item of
				  service, or
c. all services for one
				  patient or subscriber within a bill or invoice.
d. The term "claim" does not include claims
				  for payment under the Medicare program (including claims under Medicare
				  Advantage and Medicare Prescription Drug Plans), FEHB or other federally
				  administered health care programs. The term does, however, include Rite Care
				  program claims, but not other Medicaid program claims.
e. The term "claim" does not distinguish
				  between fully insured and self-insured claims. Both fully insured and
				  self-insured claims are included.
f. The term "claim" includes claims for
				  payment processed on behalf of or for a "subject entity" (defined below) by an
				  agent, contractor, subsidiary, affiliate (as defined by R.I. Gen. Laws §
												27-35-1(a)) or
				  any other entity, regardless of whether such claims are:
(1) forwarded to an agent, contractor,
				  subsidiary, or affiliate by a subject entity for processing; or
(2) submitted directly by a health care
				  provider or policyholder to an agent,
(3) contractor, subsidiary, or affiliate of a
				  subject entity for processing.
3. "Commissioner" means the Health Insurance
				  Commissioner.
4. "Complete claim"
				  means
a. a written or electronic claim for
				  payment;
b. submitted by a health
				  care provider or a policyholder;
c.
				  to either
(1) a subject entity or
(2) an agent, contractor, subsidiary, or
				  affiliate of a subject entity; and
d. that meets the written standard defining a
				  complete claim established by the subject entity.
e. For the purposes of this Part, an agent,
				  management company or billing agency may submit a claim on behalf of a health
				  care provider or policyholder.
5. "Contractor" means a person or entity,
				  including a preferred provider organization, that does not offer risk bearing
				  services and only offers services of its network to risk-bearing entities, and
				  a third-party administrator required to be licensed or registered R.I. Gen.
				  Laws Chapter 27-20.7, that:
a. Establishes,
				  operates or maintains a network of participating providers;
b. Contracts with an insurance company, a
				  hospital or medical or dental service plan, an employer, whether underwritten
				  or self insured, an employee organization, or any other entity, including a
				  labor/management trust, providing coverage for health care services to
				  administer a plan; and/or
c.
				  Conducts or arranges for utilization review activities pursuant to R.I. Gen.
				  Laws Chapter 23-17.12.
d. The term
				  "contractor" is not limited to those that have voluntarily registered with the
				  Rhode Island Department of Health.
6. "Date of payment" means the date on which
				  payment is issued by or on behalf of a subject entity. See also the definition
				  of "pay", "paying", or "paid" below.
7. "Date of receipt" means the date the
				  subject entity (or an agent, contractor, subsidiary, or affiliate of a subject
				  entity) receives a claim, whether via electronic submission or as a paper
				  claim.
8. "Deny" or "denying" or
				  "denied" or "denial" means a determination by a subject entity (or an agent,
				  contractor, subsidiary, or affiliate of a subject entity) that a claim is not
				  eligible for payment.
9. "Health
				  care entity" means a licensed insurance company or nonprofit hospital or
				  medical or dental service corporation or plan or health maintenance
				  organization, or a contractor as described in R.I. Gen. Laws §
											23-17.13-2(2),
				  that operates a health plan. This definition is not limited to Rhode Island
				  licensees.
10. "Health care
				  provider" means an individual clinician, either in practice independently or in
				  a group, who provides health care services in Rhode Island, and is otherwise
				  referred to as a non-institutional provider. A health care provider provides
				  health care services in Rhode Island when that individual, operating
				  independently or through a group, maintains, operates or uses an office, clinic
				  or other place of business in Rhode Island to provide health care
				  services.
11. "Health care
				  services" include, but are not limited to, medical, mental health, substance
				  abuse, dental and any other services covered under the terms of the specific
				  health plan.
12. "Health plan"
				  means a plan operated by a health care entity that provides for the delivery of
				  health care services to persons enrolled in such plans through:
a. arrangements with selected providers to
				  furnish health care services, and/or
b. financial incentive for persons enrolled
				  in the plan to use the participating providers and procedures provided for by
				  the health plan.
13.
				  "Office" or "OHIC" means the Office of the Health Insurance
				  Commissioner.
14. "Operating in
				  this state" means
a. to carry on, conduct or
				  transact any aspect of the processing of a claim in Rhode Island;
b. to be engaged in the business of insurance
				  in Rhode Island;
c. to conduct
				  operations in Rhode Island as a health maintenance organization, nonprofit
				  medical service corporation, nonprofit hospital service corporation, nonprofit
				  dental service corporation, licensed third party administrator or
				  contractor;
d. to offer health
				  insurance in Rhode Island under R.I. Gen. Laws Chapter 27-18;
e. to operate a provider network in Rhode
				  Island for the purpose of the delivery of health care services to health plan
				  enrollees; or
f. to operate in
				  Rhode Island as a health plan certified by OHIC pursuant to R.I. Gen. Laws
				  Chapter 27-18.8.
15.
				  "Pay" or "paying" or "paid" means that a claim payment has been issued by or on
				  behalf of a subject entity. A payment is considered issued on the date payment
				  is made, not on the date it is received. In cases where a claim is processed
				  but a payment is not actually due from a subject entity (e.g., where the amount
				  of the claim is applied to a deductible amount), the claim will be considered
				  paid on the date of final adjudication of the claim, not on the date when
				  notice of the final adjudication is received.
16. "Pend" or "pending" or "pended" means
				  that a determination has been made by a subject entity (or an agent,
				  contractor, subsidiary, or affiliate of a subject entity) that a claim is not
				  complete or is otherwise not immediately payable.
17. "Policyholder" means a person covered
				  under a health plan or a representative designated by such person.
				  "Policyholder" includes those who are usually described in insurance contracts
				  and employee benefit plans as a "subscriber", "participant", "member",
				  "dependent", "beneficiary", "policyholder" or other similar term.
				  "Policyholder" does not include any non-person or entity described as
				  "policyholder" in a group contract or agreement.
18. "Process" or "processing" or "processed"
				  refers to the paying, pending or denying of a claim.
19. "Subject entity" means a health care
				  entity operating in this state or a health care entity that operates a health
				  plan in this state.
20.
				  "Substantial compliance" means that the ratio of the number of claims paid or
				  processed by a subject entity within the timeframes set forth in R.I. Gen. Laws
				  §§
											27-18-61(a),
				  27-19-52(a),
				  27-20-41(a) or
				  27-41-64(a) to
				  the number of claims received, is 0.95 or greater.