33-46-21. Insurer responsibility for compliance; periodic reviews; evaluation of adverse determinations.

An insurer shall be responsible for monitoring all utilization review activities carried out by, or on behalf of, the insurer and for ensuring that all requirements of this chapter and applicable rules and regulations are met. The insurer also shall ensure that appropriate personnel have operational responsibility for the conduct of the insurer’s utilization review program.#

Whenever an insurer contracts with a private review agent or utilization review entity to perform services subject to this chapter or applicable rules and regulations, the Commissioner shall hold the insurer responsible for monitoring the activities of such private review agent or utilization review entity and for ensuring that the requirements of this chapter and applicable rules and regulations are met.#

A private review agent or utilization review entity shall use documented clinical criteria that are based on sound clinical evidence and which are evaluated periodically to assure ongoing efficacy.#

Qualified healthcare professionals shall administer the utilization review program and oversee utilization review decisions. An initial screening of prior authorization requests may be completed without providing the treating provider or other qualified healthcare professional with the opportunity to speak with a clinical peer of the private review agent or utilization review entity. Such an opportunity shall be provided, however, before an appeal. If a private review agent or utilization review entity questions the medical necessity of a healthcare service, such agent or entity shall notify the covered person’s treating provider, or such provider’s appropriately qualified designee familiar with the patient’s case, that medical necessity is being questioned in accordance with the provisions of paragraph (5) of subsection (a) of Code Section 33-46-6.#

An insurer shall provide covered persons and participating providers with access to its utilization review staff by telephone or through synchronous digital text or voice messaging or similar technology in accordance with state and federal privacy laws. A clinical peer shall evaluate the clinical appropriateness of adverse determinations.#