376.1363. Utilization review decisions, procedures.
Utilization review decisions, procedures.
376.1363. 1. A health carrier shall maintain written procedures formaking utilization review decisions and for notifying enrollees andproviders acting on behalf of enrollees of its decisions. For purposes ofthis section, "enrollee" includes the representative of an enrollee.
2. For initial determinations, a health carrier shall make thedetermination within two working days of obtaining all necessaryinformation regarding a proposed admission, procedure or service requiringa review determination. For purposes of this section, "necessaryinformation" includes the results of any face-to-face clinical evaluationor second opinion that may be required:
(1) In the case of a determination to certify an admission, procedureor service, the carrier shall notify the provider rendering the service bytelephone within twenty-four hours of making the initial certification, andprovide written or electronic confirmation of the telephone notification tothe enrollee and the provider within two working days of making the initialcertification;
(2) In the case of an adverse determination, the carrier shall notifythe provider rendering the service by telephone within twenty-four hours ofmaking the adverse determination; and shall provide written or electronicconfirmation of the telephone notification to the enrollee and the providerwithin one working day of making the adverse determination.
3. For concurrent review determinations, a health carrier shall makethe determination within one working day of obtaining all necessaryinformation:
(1) In the case of a determination to certify an extended stay oradditional services, the carrier shall notify by telephone the providerrendering the service within one working day of making the certification,and provide written or electronic confirmation to the enrollee and theprovider within one working day after the telephone notification. Thewritten notification shall include the number of extended days or nextreview date, the new total number of days or services approved, and thedate of admission or initiation of services;
(2) In the case of an adverse determination, the carrier shall notifyby telephone the provider rendering the service within twenty-four hours ofmaking the adverse determination, and provide written or electronicnotification to the enrollee and the provider within one working day of thetelephone notification. The service shall be continued without liabilityto the enrollee until the enrollee has been notified of the determination.
4. For retrospective review determinations, a health carrier shallmake the determination within thirty working days of receiving allnecessary information. A carrier shall provide notice in writing of thecarrier's determination to an enrollee within ten working days of makingthe determination.
5. A written notification of an adverse determination shall includethe principal reason or reasons for the determination, the instructions forinitiating an appeal or reconsideration of the determination, and theinstructions for requesting a written statement of the clinical rationale,including the clinical review criteria used to make the determination. Ahealth carrier shall provide the clinical rationale in writing for anadverse determination, including the clinical review criteria used to makethat determination, to any party who received notice of the adversedetermination and who requests such information.
6. A health carrier shall have written procedures to address thefailure or inability of a provider or an enrollee to provide all necessaryinformation for review. In cases where the provider or an enrollee willnot release necessary information, the health carrier may denycertification of an admission, procedure or service.
(L. 1997 H.B. 335)