33-46-6. Requirements for certification; utilization of nationally recognized accreditation standards; website identifying nationally recognized accreditation entities.

As a condition of certification or renewal thereof, a private review agent or utilization review entity shall be required to maintain compliance with the following:#

1. (1)

   Where not otherwise addressed in this chapter or department regulations, the medical protocols including reconsideration and appeal processes as well as other relevant medical issues used in the private review or utilization review program shall be established with input from healthcare providers who are from a major area of specialty and certified by the boards of the American medical specialties selected by a private review agency or utilization review entity and documentation of such protocols shall be made available upon request of healthcare providers; or, where not so addressed, protocols, including reconsideration and appeal processes as well as other relevant healthcare issues used in such program, shall be established based on input from persons who are licensed in the appropriate healthcare provider’s specialty recognized by a licensure agency of such a healthcare provider;#

2. (2)

   All preadmission review programs shall provide for immediate hospitalization of any patient for whom the treating healthcare provider determines the admission to be of an emergency nature, so long as medical necessity is subsequently documented;#

3. (3)

   In the absence of any contractual agreement between the healthcare provider and the insurer, the responsibility for obtaining prior authorization as well as concurrent review required by the insurer shall be the responsibility of the covered person pursuant to Chapter 20E of this title;#

4. (4)

   In cases where a private review agent or utilization review entity is responsible for utilization review for an insurer or claim administrator, such agent or entity should respond promptly and efficiently in accordance with this chapter to all requests including concurrent review in a timely method, and a method for an expedited authorization process shall be available in the interest of efficient patient care;#

5. (5)

   In any instances where the private review agent or utilization review entity is questioning the medical necessity of care, the treating health care provider, or such provider’s appropriately qualified designee, shall be able to discuss the plan of treatment with a clinical peer trained in a related specialty and no adverse determination shall be made by the private review agent or utilization review entity until an effort has been made to discuss the patient’s care with the patient’s treating provider, or such provider’s appropriately qualified designee who shall be familiar with the patient’s case, during normal working hours. Such effort shall include contacting the treating provider or his or her designee, implementing a callback telecommunications system, or the use of a public website whereby such provider or designee may elect to receive a scheduled communication at a later time in the event that a clinical peer is not available. In the event of an adverse determination, notice to the provider will specify the reasons for the review determination;#

6. (6)

   A private review agent or utilization review entity shall assign a reasonable target review period in accordance with this chapter for each admission promptly upon notification by the healthcare provider. Once a target length of stay has been agreed upon with the healthcare provider, the utilization review agent or utilization review entity will not attempt to contact the healthcare provider or patient for further information until the end of that target review period except for discharge planning purposes or in response to a contact by a patient or healthcare provider. The provider or the healthcare facility will be responsible for alerting the utilization review agent or utilization review entity in the event of a change in proposed treatment. At the end of the target period, the private review agent or utilization review entity will review the care for a continued stay;#

7. (7)

   A private review agent or utilization review entity shall not enter into any incentive payment provision contained in a contract or agreement with an insurer which is based on reduction of services or the charges thereof, reduction of length of stay, or utilization of alternative treatment settings;#

8. (8)

   Any healthcare provider may designate one or more individuals to be contacted by the private review agent or utilization review entity for information or data. In the event of any such designation, the private review agent or utilization review entity shall not contact other employees or personnel of the healthcare provider except with prior consent to the healthcare provider. An alternate will be available during normal business hours if the designated individual is absent or unavailable; and#

9. (9)

   Private review agents and utilization review entities shall develop applicable utilization review plans and conduct utilization review in accordance with standards as set forth under this chapter and rules and regulations adopted by the Commissioner.#

The Commissioner may consider nationally recognized accreditation standards for utilization review and may adopt by rule or regulation any such standards for the purposes of enforcing this chapter, to the extent such standards do not conflict with this chapter.#

The Commissioner may maintain on the department website a list of nationally recognized accreditation entities.#

As a condition of certification or renewal thereof, a private review agent or utilization review entity shall be required to maintain compliance with the following:#

1. (1)

   Where not otherwise addressed in this chapter or department regulations, the medical protocols including reconsideration and appeal processes as well as other relevant medical issues used in the private review or utilization review program shall be established with input from healthcare providers who are from a major area of specialty and certified by the boards of the American medical specialties selected by a private review agency or utilization review entity and documentation of such protocols shall be made available upon request of healthcare providers; or, where not so addressed, protocols, including reconsideration and appeal processes as well as other relevant healthcare issues used in such program, shall be established based on input from persons who are licensed in the appropriate healthcare provider’s specialty recognized by a licensure agency of such a healthcare provider;#

2. (2)

   All preadmission review programs shall provide for immediate hospitalization of any patient for whom the treating healthcare provider determines the admission to be of an emergency nature, so long as medical necessity is subsequently documented;#

3. (3)

   In the absence of any contractual agreement between the healthcare provider and the insurer, the responsibility for obtaining prior authorization as well as concurrent review required by the insurer shall be the responsibility of the covered person pursuant to Chapter 20E of this title;#

4. (4)

   In cases where a private review agent or utilization review entity is responsible for utilization review for an insurer or claim administrator, such agent or entity should respond promptly and efficiently in accordance with this chapter to all requests including concurrent review in a timely method, and a method for an expedited authorization process shall be available in the interest of efficient patient care;#

5. (5)

   In any instances where the private review agent or utilization review entity is questioning the medical necessity of care, the treating health care provider, or such provider’s appropriately qualified designee, shall be able to discuss the plan of treatment with a clinical peer trained in a related specialty and no adverse determination shall be made by the private review agent or utilization review entity until an effort has been made to discuss the patient’s care with the patient’s treating provider, or such provider’s appropriately qualified designee who shall be familiar with the patient’s case, during normal working hours. In the event of an adverse determination, notice to the provider will specify the reasons for the review determination;#

6. (6)

   A private review agent or utilization review entity shall assign a reasonable target review period in accordance with this chapter for each admission promptly upon notification by the healthcare provider. Once a target length of stay has been agreed upon with the healthcare provider, the utilization review agent or utilization review entity will not attempt to contact the healthcare provider or patient for further information until the end of that target review period except for discharge planning purposes or in response to a contact by a patient or healthcare provider. The provider or the healthcare facility will be responsible for alerting the utilization review agent or utilization review entity in the event of a change in proposed treatment. At the end of the target period, the private review agent or utilization review entity will review the care for a continued stay;#

7. (7)

   A private review agent or utilization review entity shall not enter into any incentive payment provision contained in a contract or agreement with an insurer which is based on reduction of services or the charges thereof, reduction of length of stay, or utilization of alternative treatment settings;#

8. (8)

   Any healthcare provider may designate one or more individuals to be contacted by the private review agent or utilization review entity for information or data. In the event of any such designation, the private review agent or utilization review entity shall not contact other employees or personnel of the healthcare provider except with prior consent to the healthcare provider. An alternate will be available during normal business hours if the designated individual is absent or unavailable; and#

9. (9)

   Private review agents and utilization review entities shall develop applicable utilization review plans and conduct utilization review in accordance with standards as set forth under this chapter and rules and regulations adopted by the Commissioner.#

The Commissioner may consider nationally recognized accreditation standards for utilization review and may adopt by rule or regulation any such standards for the purposes of enforcing this chapter, to the extent such standards do not conflict with this chapter.#

The Commissioner may maintain on the department website a list of nationally recognized accreditation entities.#