§ 27-41-69 - Post-payment audits.
SECTION 27-41-69
§ 27-41-69 Post-payment audits. – (a) Except as otherwise provided herein, any review, audit or investigation bya health maintenance organization of a health care provider's claims whichresults in the recoupment or set-off of funds previously paid to the healthcare provider in respect to such claims shall be completed no later than two(2) years after the completed claims were initially paid. This section shallnot restrict any review, audit or investigation regarding claims that aresubmitted fraudulently, are subject to a pattern of inappropriate billing, arerelated to coordination of benefits, or are subject to any federal law orregulation that permits claims review beyond the period provided herein.
(b) No health care provider shall seek reimbursement from apayer for underpayment of a claim later than two (2) years from the date thefirst payment on the claim was made, except if the claim is the subject of anappeal properly submitted pursuant to the payer's claims appeal policies or theclaim is subject to continual claims submission.
(c) For the purposes of this section, "health care provider"means an individual clinician, either in practice independently or in a group,who provides health care services, and otherwise referred to as anon-institutional provider.