Benefit Determination Review

What is a Review Agent?

Review agent means a person or healthcare entity performing benefit determination reviews that is either employed by, affiliated with, under contract with, or acting on behalf of a healthcare entity.

What is a Health Care Entity?

Health care entity means an insurance company licensed, or required to be licensed, by the state of Rhode Island or other entity subject to the jurisdiction of the Commissioner or the jurisdiction of the department of business regulation that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing health insurance, accident and sickness insurance, health benefits, or healthcare services.

What is the difference between Administrative and Non-Administrative benefit determination?

Administrative Benefit Determination is defined as any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, a determination that an administrative requirement was not followed, or any rescission of coverage.

Non-Administrative Benefit Determination Review is defined as any adverse benefit determination that requires or involves the use of medical judgment or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the health-care entity's formulary.

For additional regulatory information, please refer to OHIC’s Regulation Page.