Definitions; Scope; Registration; Contracting entity rights and responsibilities; Third-party rights and responsibilities; Unauthorized access to provider network contracts; Enforcement
Section 27-20.10-1. Definitions
For purposes of this chapter, the following definitions shall apply:
(1) “Contracting entity” means any person or entity that enters into direct contracts with providers for the delivery of health care services in the ordinary course of business.
(2) “Control” and “under common control with” shall mean possession, directly or indirectly, of the power to direct or cause the direction of the management and policies of an entity through the ownership of fifty percent (50%) or more of the voting securities of the entity.
(3) “Covered individual” means an individual who is covered under a health insurance plan.
(4) “Department” means the department of business regulation.
(5) “Direct notification” is a written or electronic communication from a contracting entity to a provider documenting a third-party access to a provider network.
(6) “Health care services” means services for the diagnosis, prevention, treatment or cure of a health condition, illness, injury or disease.
(7)(i) “Health insurance plan” means any hospital and medical expense incurred policy, nonprofit health care service plan contract, health maintenance organization subscriber contract, or any other health care plan or arrangement that pays for or furnishes medical or health care services, whether by insurance or otherwise.
(ii) “Health insurance plan” shall not include one or more, or any combination of, the following: coverage only for accident, or disability income insurance; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers’ compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; coverage similar to the foregoing as specified in federal regulation issued pursuant to P.L. No. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits; dental or vision benefits; benefits for long-term care, nursing home care, home health care, or community-based care; specified disease or illness coverage, hospital indemnity or other fixed indemnity insurance, or such other similar, limited benefits as are specified in regulations; Medicare supplemental health insurance as defined under § 1882(g)(1) of the Social Security Act [42 U.S.C. § 1395ss]; coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code; or other similar limited benefit supplemental coverages.
(8)(i) “Provider” means a physician, a physician organization, or a physician hospital organization that is acting exclusively as an administrator on behalf of a provider to facilitate the provider’s participation in health care contracts.
(ii) “Provider” does not include a physician organization or physician hospital organization that leases or rents the physician organization’s or physician hospital organization’s network to a third-party.
(9) “Provider network contract” means a contract between a contracting entity and a provider specifying the rights and responsibilities of the contracting entity and provider for the delivery of and payment for health care services to covered individuals.
(10) “Third-party” means an organization that enters into a contract with a contracting entity or with another third-party to gain access to a provider network contract.
Section 27-20.10-2. Scope
(a) This chapter shall apply to health insurance corporations subject to chapter 1 of this title, nonprofit hospital or medical service corporations subject to chapters 19 or 20 of this title, and health maintenance organization incorporated or resident in the state of Rhode Island.
(b) This chapter shall not apply to provider network contracts for services provided to Medicaid, Medicare or state children’s health insurance program (SCHIP) beneficiaries.
(c) This chapter shall not apply in circumstances where access to the provider network contract is granted to an entity operating under common control with or under the same brand licensee program as the contracting entity (“affiliate entities”). Contracting entities shall, however, make the list of such affiliate entities available on a website or by other means. The affiliate entities shall have the same rights and responsibilities under the provider network contracts as the contracting entities.
(d) This chapter shall not apply to a contract between a contracting entity and a discount medical plan organization.
(e) This chapter shall not apply to any entity, such as employers, church plans or government plans, receiving administrative services from the contracting entity or an affiliate entity. Such exempt entities shall have the same rights and responsibilities under the provider network contracts as the contracting entities, except the exempt entities shall not grant access to a provider’s health care services and contractual discounts to any other entity.
Section 27-20.10-3. Registration
(a) Any person that commences business as a contracting entity shall register with the department within thirty (30) days of commencing business in the state of Rhode Island unless such person is licensed by the department as an insurer. Upon passage of this chapter, each person not licensed by the department as a contracting entity shall register with the department within ninety (90) days of the effective date of this chapter.
(1) Registration shall consist of the submission of the following information:
(i) The official name of the contracting entity, including and d/b/a designations used in this state;
(ii) The mailing address and main telephone number for the contracting entity’s main headquarters; and
(iii) The name and telephone number of the contracting entity’s representative who shall serve as the primary contact with the department.
(2) The information required by this section shall be submitted in written or electronic format, as prescribed by the department.
(b) The department may collect a reasonable fee for the purpose of administering the registration process.
Section 27-20.10-4. Contracting entity rights and responsibilities
(a) A contracting entity may not grant access to a provider’s health care services and contractual discounts pursuant to a provider network contract unless:
(1) The provider network contract specifically states that the contracting entity may enter into an agreement with a third-party allowing the third-party to obtain the contracting entity’s rights and responsibility’s under the provider network contract as if the third-party were the contracting entity; and
(2) The third-party accessing the provider network contract is contractually obligated to comply with all applicable terms, limitations and conditions of the provider network contract.
(b) A contracting entity that grants access to a provider’s health care services and contractual discounts pursuant to a provider network contract shall:
(1) Identify and provide to the provider, upon request at the time a provider network contract is entered into with a provider, a written or electronic list of all third-parties known at the time of contracting, to which the contracting entity has or will grant access to the provider’s health care services and contractual discounts pursuant to a provider network contract;
(2) Maintain an Internet website or other readily available mechanism, such as a toll-free telephone number, through which a provider may obtain a listing, updated at least every ninety (90) days, of the third-parties to which the contracting entity or another third-party has executed contracts to grant access to such provider’s health care services and contractual discounts pursuant to a provider network contract;
(3) Provide each third-party who contracts with the contracting entity to gain access to the provider network contract with a summary of the contracting entity’s current standard provider contract terms;
(4) Require that the third-party who contracts with the contracting entity to gain access to the provider network contract identify the source of the contractual discount taken by the third-party on each remittance advice (RA) or explanation of payment (EOP) form furnished to a health care provider when such discount is pursuant to the contracting entity’s provider network contract;
(5)(i) Notify the third-party who contracts with the contracting entity to gain access to the provider network contract of the termination of the provider network contract no later than ten (10) days after receipt of notice of the termination of the provider network contract;
(ii) Require those that are by contract eligible to claim the right to access a provider’s discounted rate to cease claiming entitlement to those rates or other contracted rights or obligations for services rendered after termination of the provider network contract; and
(iii) The notice required under paragraph (i) above can be provided through any reasonable means, including, but not limited to: written notice, electronic communication, or an update to electronic database or other provider listing.
(c) Subject to any applicable continuity of care requirements, agreements, or contractual provisions:
(1) A third-party’s right to access a provider’s health care services and contractual discounts pursuant to a provider network contract shall terminate on the date the provider network contract is terminated;
(2) Claims for health care services performed after the termination date of the provider network contract are not eligible for processing and payment in accordance with the provider network contract; and
(3) Claims for health care services performed before the termination date of the provider network contract, but processed after the termination date, are eligible for processing and payment in accordance with the provider network contract.
(d)(1) All information made available to provider in accordance with the requirements of this chapter shall be confidential and shall not be disclosed to any person or entity not involved in the provider’s practice or the administration thereof without the prior written consent of the contracting entity.
(2) Nothing contained in this chapter shall be construed to prohibit a contracting entity from requiring the provider to execute a reasonable confidentiality agreement to ensure that confidential or proprietary information disclosed by the contracting entity is not used for any purpose other than the provider’s director practice management or billing activities.
Section 27-20.10-5. Third-party rights and responsibilities
(a) A third-party, having itself been granted access to a provider’s health care services and contractual discounts pursuant to a provider network contract, that subsequently grants access to another third-party is obligated to comply with the rights and responsibilities imposed on contracting entities under § 27-20.10-4 and 27-20.10-6.
(b) A third-party that enters into a contract with another third-party to access a provider’s health care services and contractual discounts pursuant to a provider network contract is obligated to comply with the rights and responsibilities imposed on third-parties under this § 27-20.10-5.
(c)(1) A third-party will provide to the contracting entity the location of a website, or identify another readily available mechanism such as a toll-free telephone number, which the contracting entity will make available to the providers under the provider network contract accessed through the contracting entity. The website or other readily available mechanism will identify the name of the person or entity to which the third-party subsequently grants access to the provider’s health care services and contractual discounts pursuant to the provider network contract.
(2) The website will allow the providers under the contracting entity’s provider network contract access to the information referenced in (c)(1) above, and will be updated on a routine basis as additional persons or entities are granted access. The website must be updated to reflect all current persons and entities with access every ninety (90) days. Upon request, a contracting entity shall make updated access information available to a provider via telephone or through direct notification.
Section 27-20.10-6. Unauthorized access to provider network contracts
(a) It is an unfair insurance practice for the purposes of chapter 27-29 of the Rhode Island general laws to knowingly access or utilize a provider’s contractual discount pursuant to a provider network contract without a contractual relationship with the provider, contracting entity, or third-party, as specified in this chapter;
(b) Contracting entities and third-parties are obligated to comply with subdivisions 27-20.10-4(b)(2) or 27-20.10-5(c)(1) and (2) concerning the services referenced on a remittance advice (RA) or explanation of payment (EOP). A provider may refuse the discount taken on the (RA) or (EOP) if the discount is taken without a contractual basis or in violation of these sections. However, an error in the (RA) or (EOP) may be corrected within thirty (30) days following notice by the provider.
(c) A contracting entity may not lease, rent, or otherwise grant to a third-party, access to a provider network contract unless the third-party accessing the health care contract is:
(1) A payer or third-party administrator or another entity that administers or processes claims on behalf of the payer;
(2) A preferred provider organization or preferred provider network, including a physician organization or physician-hospital organization; or
(3) An entity engaged in the electronic claims transport between the contracting entity and the payer that does not provide access to the provider’s services and discount to any other third-party.
Section 27-20.10-7. Enforcement
Enforcement of this model will follow that of chapter 27-29 of the Rhode Island general laws, “Unfair Competition and Practices.”