Health plans cannot reject bills solely over another party’s involvement

Health plans cannot deny payment solely because a medical bill may arise from a claim or incident involving another party. The rule covers health plans operating in Rhode Island, including insurers, nonprofit health coverage organizations, and health maintenance organizations. Workers’ compensation claims, which cover work-related injuries, are excluded. The rule does not guarantee payment or prevent denial for other reasons.

A doctor’s failure to submit a medical bill to a health insurer solely because it may involve another party counts as professional misconduct. The rule applies under Rhode Island’s medical licensing and discipline law. Workers’ compensation claims for work-related injuries are excluded. The refusal must rest solely on the bill’s possible connection to a claim or incident involving another party.