Section 230-RICR-20-30-6.4 - Prompt Processing of ClaimsA. 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.2. The subject entity shall pay all complete claims for health care services within the timeframes established by § 6.4(A)(1) of this Part unless an exception set out in § 6.4(A)(3) of this Part applies.3. Exceptions to the requirements of this Part are as follows: a. No subject entity shall be in violation of this Part for a claim submitted by a health care provider or policyholder if: (1) failure to comply with this Part is caused by a directive from a court or federal or state agency;(2) the subject entity is in liquidation or rehabilitation or is operating in compliance with a court-ordered plan of rehabilitation; or(3) compliance by the subject entity is rendered impossible due to matters beyond the subject entity's control and which are not caused by the subject entity.(4) A subject entity that intends to claim an exemption under § 6.4(A) of this Part must notify the OHIC in writing of its intent to claim an exemption and the facts or circumstances supporting the claimed exemption. (AA) Example 1 - A Rhode Island physician submits a complete electronic claim to a subject entity. The subject entity, however, is in receivership and is being liquidated. This claim is not subject to the processing timeframes established by this Part.(BB) Example 2 - A Rhode Island physician submits a complete electronic claim to a subject entity. The subject entity's claim processing system has been damaged by a natural disaster and is temporarily nonfunctional. This claim is not subject to the processing timeframes established by this Part because: (i) compliance was rendered impossible, (ii) the damage to the claims processing system was due to matters beyond the subject entity's control and(iii) the damage to the claims processing system was not caused by the subject entity.(CC) Example 3 - A Rhode Island physician submits a complete electronic claim to a subject entity on May 1st. The subject entity receives the claim on May 1st. Thereafter, the subject entity's malfunctioning claim processing system "loses" the claim for two months. This claim is subject to the processing timeframes established by this Part. The delay in processing was due to the subject entity's own system failure and was therefore within the control of the subject entity.b. No subject entity shall be in violation of this Part for any claim (1) Initially submitted more than ninety days after the health care service is rendered; or(2) Resubmitted more than ninety days after the date the health care provider received the notice provided for in § 6.4(B) of this Part.(3) This exception shall not apply in the event that the submission of a claim within the ninety-day period established in § 6.4(A) of this Part is rendered impossible due to matters beyond the control of the health care provider and that were not caused by such health care provider. A health care provider invoking this exception to the ninety-day period must notify the subject entity of (AA) the matters beyond the control of the health care provider rendered compliance with the ninety-day limits impossible and (BB) that the noncompliance was not caused by the health care provider. Should a dispute arise regarding provider's reasons for noncompliance with the ninety-day limits, the dispute will be resolved by the OHIC.c. Examples: (1) Example 1. A Rhode Island physician submits a complete electronic claim to a subject entity on May 1st. The health care services were rendered on January 1st. This claim is not subject to the processing timeframes established by this Part.(2) Example 2. A Rhode Island physician submits an electronic claim to a subject entity on May 1st. The subject entity pends the claim on May 5th, notifies the physician in writing of the reasons for pending the claim and provides an explanation of the additional information required to process the claim. On May 15th the physician resubmits the claim electronically. The resubmitted claim is a complete claim. The subject entity receives the claim on May 15th. The resubmitted claim is subject to the processing timeframes established by this Part and must be paid within thirty days of receipt by the subject entity. June 14th is thirty days from May 15th. The subject entity has until June 14th to pay the claim.(3) Example 3. A Rhode Island physician submits an electronic claim to a subject entity on May 1st. The subject entity pends the claim on May 5th, notifies the physician in writing of the reasons for pending the claim and provides an explanation of the additional information required to process the claim. On November 1st, the physician resubmits the claim electronically. The resubmitted claim is a complete claim. The resubmitted claim is not subject to the processing timeframes established by this Part because the claim was submitted more than ninety days after the date the physician received written notice from the subject entity regarding the pended claim.d. No subject entity shall be in violation of this Part while the claim is pending due to a fraud investigation by a state or federal agency.e. No subject entity shall be obligated under this Part to pay interest to any health care provider or policyholder for any claim if the OHIC has made a finding that such subject entity is in substantial compliance with this Part. This exception to the requirement to pay interest applies only to claims submitted during the period of time specified in the OHIC's order setting forth the finding that the subject entity is in substantial compliance.f. A subject entity may petition the OHIC for a waiver of the provisions of this Part for a period not to exceed ninety calendar days if the subject entity certifies to the OHIC that it is converting or substantially modifying its claims processing systems and that said conversion or modification process will render it unable to comply with the requirements this Part.4. A subject entity that fails to pay the health care provider or policyholder after receipt of a complete claim for health care services within the timeframes established by § 6.4(A)(1) of this Part shall pay to the health care provider or the policyholder who submitted such claim, in addition to any reimbursement for health care services provided, interest which shall accrue at the rate of twelve percent per annum commencing on the thirty-first day after receipt of a complete electronic claim or on the forty-first day after receipt of a complete written claim, and ending on the date of payment to the health care provider or the policyholder.5. The subject entity shall pay the interest required by § 6.4(A)(4) of this Part unless a. an exception set out in § 6.4(A)(3) of this Part applies orb. the subject entity is deemed by the Commissioner to be in substantial compliance, in accordance with the requirements set out in § 6.6 of this Part, during the period in which the claim is submitted.B. Denial or Pending of Claims 1. If a subject entity denies or pends a claim, the subject entity shall have thirty calendar days from receipt of the claim to notify in writing the health care provider or policyholder of any and all reasons for denying or pending the claim and what, if any, additional information is required to process the claim.2. No subject entity may limit the time period in which additional information may be submitted to complete a claim.C. Resubmission of Claims 1. Any claim that is resubmitted by a health care provider or policyholder shall be processed by the subject entity pursuant to the provisions of § 6.4(A) and (B) of this Part.2. Any denied or pended claim for which additional information is submitted by a health care provider or policyholder shall be processed by the subject entity pursuant to the timeframes set forth in § 6.4(A) and (B) of this Part as of the date the additional information was submitted.230 R.I. Code R. 230-RICR-20-30-6.4