230 R.I. Code R. 230-RICR-20-30-14.4

Current through December 3, 2024

Section 230-RICR-20-30-14.4 - General Requirements

A. A review agent must establish and submit to the Office standards and procedures for its benefit determination activity that demonstrates compliance with the Act and this Part to include administrative and non-administrative benefit determinations as defined in this Part. This shall be submitted through a certification, recertification and material change process determined by the Commissioner, including as set forth in this Part.

B. A review agent operating in Rhode Island shall provide evidence of adherence to the following:

1. That it shall not conduct benefit determination reviews in the state unless the Commissioner has granted the review agent a certificate pursuant to the Act and this Part;

2. Individuals shall not be required to hold a separate review agent certification under the Act or this Part when acting as either an employee of, an affiliate of, a contractor for, or otherwise acting on behalf of a certified review agent, however, the review agent shall be responsible for these individuals in the same manner that the review agent is responsible for its delegates under the Act and this Part;

3. Submission of a recertification application every two (2) years in form and content consistent with instructions issued by the Office for that purpose;

4. Notification and explanation to the Office at least thirty (30) calendar days prior to implementation of any systemic change to any of the certified review agent's operations to include the information on file with the Office;

5. Upon a determination by the Office that a systemic change constitutes a material change, shall file an application consistent with instructions and requests for information issued by the Office for that purpose; and

6. A systemic change determined by the Office to be a material change shall not be implemented until receipt of written approval for the material change by the Office.

C. A review agent applying for certification, recertification or material change approval shall provide information to the Office sufficient to enable the Office to evaluate compliance with the requirements of the Act and this Part according to instructions issued as a guidance document by the Office for that purpose.

D. The cost of the application processes (certification, recertification, and material change), application reviews, complaint processing, investigations, and other activities related to obtaining and maintaining review agency certifications shall be borne by the review agents, as determined by the Commissioner, including:

1. An application fee established by the Commissioner for each application processed, not to exceed five hundred dollars ($500), which must accompany each application.

2. Pursuant to R.I. Gen. Laws § 27-18.9-3(h), the total cost of obtaining and maintaining a certificate under this Act and in compliance with the requirements of the applicable rules and regulations shall be borne by the applicant and shall include one hundred and fifty percent (150%) of the total salaries paid to the personnel engaged in certifications and ensuring compliance with the requirements herein of this Part and the applicable rules and regulations.

3. Pursuant to R.I. Gen. Laws § 27-18.9-3(h), these monies shall be paid to the Commissioner to and for the use of the Office and shall be in addition to any taxes and fees otherwise payable to the state.

4. The Commissioner may not issue a certification, recertification, approval of a material change, or may suspend a currently certified review agent, if a review agent fails to pay any of the fees, assessments and costs noted above in a timely manner.

E. Pursuant to R.I. Gen. Laws § 27-18.9-3(e), a certificate issued under this Part is not transferable, and the transfer of fifty percent (50%) or more of the ownership of a review agent shall be deemed a transfer.

F. Review agents must maintain and submit to the Office its most current grievance and complaint process that adheres to and includes the following minimal requirements:

1. Written processes whereby the beneficiary, a beneficiary's authorized representatives, or health care providers may seek resolution of complaints and grievances, and other matters, of which the review agent has received oral or written notice;

2. Reasonable timeframes for the resolution of beneficiary, authorized representative of beneficiary, and provider complaints and grievances of not more than thirty (30) calendar days from the date the review agent receives the oral or written notice unless granted an extension by the Commissioner;

3. A substantiation to the satisfaction of the Commissioner that there is reasonable communication on an annual basis either directly or through the health care entity to the network plan beneficiaries and providers that explains the grievance and complaint process to include guidance for distinguishing between a complaint/grievance and a benefit determination appeal and the rights associated with each; and

4. Internal monitoring of complaints and grievances and reporting of complaints and grievances in form and content consistent with instructions issued by the Office for that purpose.

G. In accordance with the purpose section, R.I. Gen. Laws §§ 27-18.9-1, 27-18.8-3(b) and 27-9.1-4(a)(3) through (4), each agency shall perform its benefit determination and appeals processes defined in this Part, in a manner to ensure quality, access, and continuity of care (to include transition of care) and the welfare and safety of the patient.

H. Each agency shall develop, implement and maintain a quality assurance program that includes the agency's oversight of all activities, whether or not delegated, subject to the Act and this Part. This quality assurance program shall include a process to regularly evaluate and determine whether the agency's activities are being performed in a manner that maintains the quality of services delivered to its beneficiaries; and assures that the agency's activities do not adversely affect the delivery of covered services.

I. Each review agent shall cooperate with all compliance reviews and investigations conducted by the Office.

J. Each review agent shall ensure that all applicable federal and state confidentiality laws are followed.

230 R.I. Code R. 230-RICR-20-30-14.4

Adopted effective 6/9/2019