Office of Managed Care Regulation

Mission:  The mission of the Office of Managed Care Regulation (OMCR) is to protect Rhode Island health care consumers and providers by:

• Ensuring that health plans (HPs) and utilization review (UR) agencies adhere to the conditions, standards, and regulations of the applicable Rhode Island General Laws (RIGL);
• Ensuring quality, continuity, and access related to health care services provided via HPs;
• Monitoring obligations of HPs’ provider contracts and providing health care consumers, providers, and purchasers with information about HPs and UR agencies;
• Ensuring UR agencies are qualified to perform utilization review activities and to make informed decisions on the appropriateness of medical care; and
• Enforcing certified UR agencies’ compliance with the required denial and appeals process when UR agencies determine that requested health care services are not medically necessary and/or appropriate.

Authority:  The OMCR has delegated authority to enforce the following statutes and their accompanying rules and regulations:

• Health Care Accessibility and Quality Assurance Act (RIGL 23-17.13);
• Utilization Review Act (RIGL 23-17.12);
• Health Maintenance Organization Act (RIGL 27-41) {enforced jointly with DBR}; and
• Health Plan Modification Act (RIGL 23-17.18).

Jurisdiction:  The OMCR carries out the Department’s managed care regulatory functions under the authority of the Rules and Regulations for the Certification of Health Plans (R23-17.13-CHP) and the Rules and Regulations for the Utilization Review of Health Care Services (R23-17.12-UR) .

Certification:  All HP and UR agencies operating in RI must be certified.  Certification/re-certification applications are reviewed for document compliance.  OMCR also conducts surveys of HP and UR agencies to ensure operational compliance. All certified HPs and UR agencies must periodically report required data to the OMCR.

More information on applications for certification and downloadable forms

For a listing of all certified HP and UR agencies in RI, please refer to the links below:

• Certified HPs
• Certified UR Agencies

Complaint Management: If you have a complaint against a HP or UR agency, please contact the OMCR at (401) 222-6015. The OMCR investigates and tracks complaints from HP and UR enrollees, their representative(s), provider(s), or other concerned parties.  If needed, the OMCR conducts investigations to verify compliance with certification and regulatory requirements.