Managed Care Regulation Program
To protect Rhode Island health care consumers and providers by ensuring that Health Plans and Utilization Review agencies provide quality, continuity, and access related to health care services.
What We Do
- Certify Health Plan and Utilization Review agencies operating in Rhode Island;
- Conduct surveys, review quarterly/annual reports and perform other work to ensure that Health Plans and Utilization Review agencies are following applicable legal requirements
- Monitor obligations of Health Plan provider contracts;
- Provide health care consumers, providers, and purchasers with information about Health Plans and Utilization Review agencies;
- Ensure Utilization Review agencies are qualified to make informed decisions on the appropriateness of medical care;
- Enforce certified Utilization Review agencies’ compliance with the required denial and appeals process when health care services are deemed as not medically necessary and/or appropriate;
- Investigate and track complaints against Health Plan and Utilization Review by enrollees.