§ 27-38.2-3 - Medical necessity and appropriateness of treatment. - Rhode Island Statutes

SECTION 27-38.2-3

   § 27-38.2-3  Medical necessity andappropriateness of treatment. – (a) Upon request of the reimbursing health insurers, all providers of treatmentof mental illness shall furnish medical records or other necessary data whichsubstantiates that initial or continued treatment is at all times medicallynecessary and appropriate. When the provider cannot establish the medicalnecessity and/or appropriateness of the treatment modality being provided,neither the health insurer nor the patient shall be obligated to reimburse forthat period or type of care that was not established. The exception to thepreceding can only be made if the patient has been informed of the provisionsof this subsection and has agreed in writing to continue to receive treatmentat his or her own expense.

   (b) The health insurers, when making the determination ofmedically necessary and appropriate treatment, must do so in a mannerconsistent with that used to make the determination for the treatment of otherdiseases or injuries covered under the health insurance policy or agreement.

   (c) Any subscriber who is aggrieved by a denial of benefitsprovided under this chapter may appeal a denial in accordance with the rulesand regulations promulgated by the department of health pursuant to chapter17.12 of title 23.