27 R.I. Gen. Laws § 27-41-16. Examination: Health Maintenance Organization Act – Rhode Island
Status: Enacted Year Enacted: 1983
The director of health may make an examination concerning the quality of health care services of any health maintenance organization and the providers with whom the organization has contracts, agreements, or other arrangements as often …
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27 R.I. Gen. Laws § 27-41-69. Post-payment audits: Health Maintenance Organization Act – Rhode Island
Status: Enacted Year Enacted: 2006
Except as otherwise provided herein, any review, audit, or investigation by a health maintenance organization of a health-care provider’s claims that results in the recoupment or set-off of funds previously paid to the health-care provider …
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27 R.I. Gen. Laws §§ 27-18.9-1 through 27-18.9-15: Benefit Determination and Utilization Review Act – Rhode Island
Status: Enacted Year Enacted: 2017
Provisions govern benefit determinations and utilization review.
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305 Ill. Comp. Stat. § 5/5-30.1. Managed care protections: Medical Assistance – Illinois
Status: Enacted Year Enacted: 2014
An MCO shall pay any provider of emergency services that does not have in effect a contract with the contracted Medicaid MCO. The default rate of reimbursement shall be the rate paid under Illinois Medicaid …
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305 Ill. Comp. Stat. § 5/5-5.02. Hospital reimbursements: Medical Assistance – Illinois
Status: Enacted Year Enacted: 1989
Hospital reimbursement rates are calculated in accordance with this section.
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305 Ill. Comp. Stat. § 5/5-5.12. Pharmacy payments: Medical Assistance – Illinois
Status: Enacted Year Enacted: 1984
Pharmacies providing prescription drugs under this Article shall be reimbursed at a rate which shall include a professional dispensing fee as determined by the Illinois Department, plus the current acquisition cost of the prescription drug …
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305 Ill. Comp. Stat. § 5/5-5f. Elimination and limitations of medical assistance services: Medical Assistance – Illinois
Status: Enacted Year Enacted: 2012
Statute requires prior approval for certain services and requires the Department to establish benchmarks for hospitals to measure and align payments to reduce potentially preventable hospital readmissions, complications and unnecessary emergency room visits.
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40 Pa. Cons. Stat. § 991.2151. Certification: Quality Health Care Accountability and Protection – Pennsylvania
Status: Enacted Year Enacted: 1998
A utilization review entity may not review health care services delivered or proposed to be delivered in this Commonwealth unless the entity is certified by the department to perform utilization review.
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40 Pa. Cons. Stat. § 991.2152. Operations standards: Utilization Review – Pennsylvania
Status: Enacted Year Enacted: 1998
Outlines requirements for an entity to perform utilization review.
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40 Pa. Cons. Stat. § 991.2162. External grievance process: Quality Health Care Accountability and Protection – Pennsylvania
Status: Enacted Year Enacted: 1998
A managed care plan shall establish and maintain an external grievance process by which an enrollee or a health care provider with the written consent of the enrollee may appeal the denial of a grievance …
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40 Pa. Cons. Stat. §§ 3801 through 3806: Retroactive Denial of Reimbursements – Pennsylvania
Status: Enacted Year Enacted: 2016
An insurer that retroactively denies reimbursement to a health care provider under this chapter shall do so based upon coding guidelines and policies in effect at the time the service subject to the retroactive denial …
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40 Pa. Stat. and Pa. Cons. Stat. Ann. §§ 991.2101 through 991.2194: Quality Health Care Accountability and Protection – Pennsylvania
Status: Enacted Year Enacted: 1998
Provisions governing managed care plans to ensure quality health care including prohibitions on financial incentives and gag clauses, standards regarding utilization review, prompt paymen of claims, and general responsibilities of managed care plans. Requires the …
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40 R.I. Gen. Laws. § 40-8.4-14. Permanent joint committee on health care oversight: Health Care for Families Act – Rhode Island
Status: Enacted Year Enacted: 2000
There is hereby created a permanent legislative committee to monitor, study, report and make recommendations on all areas of health care provision, insurance, liability, licensing, cost and delivery of services, and the adequacy, efficacy and …
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40 R.I. Gen. Laws. § 40-8.4-15. Advisory commission on health care: Health Care for Families – Rhode Island
Status: Enacted Year Enacted: 2000
The commission may study all aspects of the provisions of the RIte Care and RIte Share programs involving purchasers of health care, including employers, consumers and the state, health insurers, providers of health care, and …
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40 R.I. Gen. Laws. § 40-8.4-3. Definitions: Health Care for Families Act – Rhode Island
Status: Enacted Year Enacted: 1998
Definitions related to Health Care for Families
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42 R.I. Gen. Laws § 42-157-8. Reporting: Rhode Island Health Benefit Exchange – Rhode Island
Status: Enacted Year Enacted: 2015
HealthSource RI shall provide a monthly report to the chairpersons of the house finance committee and the senate finance committee which shall include, but not be limited to, the following information: actual enrollment data by market …
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