230 R.I. Code R. 230-RICR-20-30-14.6

Current through December 3, 2024

Section 230-RICR-20-30-14.6 - Benefit Determination General Requirements

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.

B. In accordance with R.I. Gen. Laws Chapter 27-18.9 and this Part, review agents conducting utilization review shall comply with the following:

1. All initial, prospective, and concurrent non-administrative adverse benefit determinations of a health care service ordered by a physician, dentist, or other professional practitioner shall be made, documented, and signed by a licensed practitioner with the same licensure status as the ordering provider.

2. Review agents conducting utilization review are not prohibited from allowing appropriately qualified review agency staff from engaging in discussions with the attending provider, in accordance with the following:

a. The attending provider or health care facility may designate other individual(s) to speak on their behalf; and

b. Such a discussion prior to any adverse benefit determination may result in a voluntary modification of the attending provider's original request which shall not constitute an adverse benefit determination provided the following occurred and was documented by the review agent:

(1) The attending provider explicitly made a bona fide voluntary agreement to a change in his/her original order and/or explicitly made a bona fide voluntary agreement to an alternative level of care; or

(2) The attending provider's designee obtained and provided to the review agent documented consent from the attending provider that explicitly communicates the attending provider's bona fide voluntary agreement in accordance with § 14.6(B)(2)(b)(1) of this Part above.

c. Such discussions shall not constitute a substitute for the required equivalent two-way direct communication required by this Part.

3. A review agent shall not retrospectively deny authorization for health care services provided to a beneficiary when an authorization had been obtained for that service from the review agent unless:

a. The authorization was based upon inaccurate information submitted to the review agent that was material to the review; or

b. The health care services were not provided consistent with the provider's submitted plan of care and/or any material restrictions clearly included in the prior approval granted by the review agent.

4. A review agent shall comply with the following notification timeline requirements in accordance with this Part:

a. For urgent or emergent health care service claims, benefit determinations (adverse or non-adverse) shall be made;

(1) As soon as possible taking into account exigencies; and

(2) No later than seventy-two (72) hours after receipt of the claim.

b. For concurrent claims;

(1) Benefit determinations (adverse or non-adverse) shall be made no later than twenty-four (24) hours after receipt of the claim; and

(2) Where the claim has been made to the agency at least twenty-four (24) hours prior to the expiration of the relevant period of time or number of treatments, benefit determinations (adverse or non-adverse) shall be made no later than twenty-four (24) hours after receipt of the claim and prior to the expiration of the period of time or number of treatments; and

(3) The agency must be available to conduct the concurrent review twenty-four (24) hours in advance of the expiration of the period of time or the number of treatments.

c. For pre-service claims, benefit determinations (adverse or non-adverse) shall be made:

(1) Within a reasonable period of time appropriate to the medical circumstances;

(2) Prior to the service being rendered; and

(3) No later than fifteen (15) calendar days after the receipt of the claim, provided that;

(4) The above time parameters set forth in § 14.6(B)(4)(c) ((3)) of this Part may be extended for up to fifteen (15) additional calendar days:

(AA) When substantiated as being required by special circumstances; and

(BB) When the claimant is noticed within the first fifteen (15) calendar-day period of the need for such extension.

d. For post-service claims, benefit determinations (adverse or non-adverse) shall be made:

(1) No later than thirty (30) calendar days after the receipt of the claim, provided that;

(2) The above time parameters set forth in § 14.6(B)(4)(d) ((1)) of this Part may be extended for up to fifteen (15) additional calendar days:

(AA) When substantiated as being required by special circumstances; and

(BB) When the claimant is noticed within the first thirty (30) calendar day period of the need for such extension.

5. In the event where there is insufficient information from a claimant for the agency to make a utilization review determination, the agency shall adhere to or ensure conditions in accordance with R.I. Gen. Laws § 27-18.9-6(a)(5) and this Part.

a. For urgent or emergent health care services to include pre-service and concurrent claims, the notice of insufficient information shall be sent to the claimant as soon as possible and not later than the timeframes set forth in R.I. Gen. Laws § 27-18.9-6(a)(5).

b. For non-emergent pre-service, concurrent and post-service claims, the notice of insufficient information shall be sent to the claimant as soon as possible and no later than the timeframes set forth in R.I. Gen. Laws § 27-18.9-6(a)(5)(ii).

c. In the event of insufficient information in a claim, timelines for decisions and notifications set forth in §§ 14.6(B)(4) and (B)(5) of this Part, are paused from the date on which the notice is sent to the claimant and then restarted when the claimant responds to the request for information.

C. A review agent's utilization review policies shall include at a minimum the requirements stated in R.I. Gen. Laws § 27-18.9-4(b) and this Part.

D. In accordance with R.I. Gen. Laws § 27-18.9-7 and this Part, review agents making utilization review decisions shall evidence to the Commissioner and comply with the following:

1. The requirement that each review agent shall provide its clinical criteria to the Office upon request;

2. Use written clinical criteria and review procedures established according to nationally accepted standards, evidence-based medicine and protocols that are periodically evaluated and updated or other reasonable standards required by the Commissioner; and

3. Establish and employ a process to transparently incorporate and consider local variations to national standards and criteria identified in this Part including, without limitation, a process to incorporate input from local participating providers. As used in this Part, a process to incorporate and consider local variations to national standards and criteria shall mean a process that:

a. Affirmatively and meaningfully solicits, documents and reasonably incorporates input from an objective, independent and diverse pool of local providers, including local participating providers or their representatives; and

b. Reasonably considers and documents input and information received from consumer advocacy groups, healthcare professional associations and chronic disease associations, employers, sponsors of health plans or other interested parties concerning clinical criteria.

4. Ensure meaningful and reasonably understandable updated descriptions of clinical decision criteria are available to beneficiaries, providers, and the Office upon request as well as readily available and accessible on the health care entity's or the review agent's website.

E. Review agent notifications form and content requirements:

1. Health care entities and review agents shall comply with form and content notification requirements for adverse benefit determinations in accordance with R.I. Gen. Laws § 27-18.9-6(b) and this Part.

2. All review agent notification templates must be provided to the Office for review and approval by the Commissioner.

230 R.I. Code R. 230-RICR-20-30-14.6

Adopted effective 6/9/2019