230 R.I. Code R. 230-RICR-20-30-6.3

Current through December 3, 2024

Section 230-RICR-20-30-6.3 - Definitions

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.

230 R.I. Code R. 230-RICR-20-30-6.3