26.1-26.4 Health Care Service Utilization Review
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<![CDATA[CHAPTER 26.1-26.4HEALTH CARE SERVICE UTILIZATION REVIEW26.1-26.4-01. Purpose. The purpose of this chapter is to:1.Promote the delivery of quality health care in a cost-effective manner;2.Assure that utilization review agents adhere to reasonable standards for conducting<br>utilization review;3.Foster greater coordination and cooperation between health care providers and<br>utilization review agents;4.Improve communications and knowledge of benefits among all parties concerned<br>before expenses are incurred; and5.Ensure that utilization review agents maintain the confidentiality of medical records<br>in accordance with applicable laws.26.1-26.4-02. Definitions. For purposes of this chapter, unless the context requiresotherwise:1."Commissioner" means the insurance commissioner.2."Emergency medical condition" means a medical condition of recent onset and<br>severity, including severe pain, that would lead a prudent layperson acting<br>reasonably and possessing an average knowledge of health and medicine to believe<br>that the absence of immediate medical attention could reasonably be expected to<br>result in serious impairment to bodily function, serious dysfunction of any bodily<br>organ or part, or would place the person's health, or with respect to a pregnant<br>woman the health of the woman or her unborn child, in serious jeopardy.3."Emergency services" means health care services, supplies, or treatments furnished<br>or required to screen, evaluate, and treat an emergency medical condition.4."Enrollee" means an individual who has contracted for or who participates in<br>coverage under an insurance policy, a health maintenance organization contract, a<br>health service corporation contract, an employee welfare benefit plan, a hospital or<br>medical services plan, or any other benefit programproviding payment,reimbursement, or indemnification for health care costs for the individual or the<br>individual's eligible dependents.5."Health care insurer" includes an insurance company as defined in section<br>26.1-02-01, a health service corporation as defined in section 26.1-17-01, a health<br>maintenance organization as defined in section 26.1-18.1-01, and a fraternal benefit<br>society as defined in section 26.1-15.1-02.6."Provider of record" means the physician or other licensed practitioner identified to<br>the utilization review agent as having primary responsibility for the care, treatment,<br>and services rendered to an individual.7."Retrospective" means utilization review of medical necessity which is conducted<br>after services have been provided to a patient, but does not include the review of a<br>claim that is limited to an evaluation of reimbursement levels, veracity of<br>documentation, accuracy of coding, or adjudication for payment.8."Utilization review" means a system for prospective, retrospective, and concurrent<br>review of the necessity and appropriateness in the allocation of health carePage No. 1resources and services that are subject to state insurance regulation and which are<br>given or proposed to be given to an individual within this state. Utilization review<br>does not include elective requests for clarification of coverage.9."Utilization review agent" means any person or entity performing utilization review,<br>except:a.An agency of the federal government; orb.An agent acting on behalf of the federal government or the department of<br>human services, but only to the extent that the agent is providing services to<br>the federal government or the department of human services.26.1-26.4-03. Certification. A utilization review agent may not conduct utilization reviewin this state unless the utilization review agent has certified to the commissioner in writing that the<br>agent is in compliance with section 26.1-26.4-04. Certification must be made annually on or<br>before March first of each calendar year. In addition, a utilization review agent must file the<br>following information:1.The name, address, telephone number, and normal business hours of the utilization<br>review agent.2.The name and telephone number of a person for the commissioner to contact.3.A description of the appeal procedures for utilization review determinations.4.A list of the third-party payers for whom the private review agent is performing<br>utilization review in the state.A provider may request that a utilization review agent furnish the provider with the medical review<br>criteria to be used in evaluating proposed or delivered health care services.Any materialchanges in the information filed in accordance with this section must be filed with the<br>commissioner within thirty days of the change.26.1-26.4-04. Minimum standards of utilization review agents. All utilization reviewagents must meet the following minimum standards:1.Notification of a determination by the utilization review agent must be provided to the<br>enrollee or other appropriate individual in accordance with 29 U.S.C. 1133 and the<br>timeframes set forth in 29 CFR 2560.503-1.2.Any determination by a utilization review agent as to the necessity or<br>appropriateness of an admission, service, or procedure must be reviewed by a<br>physician or, if appropriate, a licensed psychologist, or determined in accordance<br>with standards or guidelines approved by a physician or licensed psychologist.3.Any notification of a determination not to certify an admission or service or<br>procedure must include the information required by 29 U.S.C. 1133 and 29 CFR<br>2560.503-1.4.Utilization review agents shall maintain and make available a written description of<br>the appeal procedure by which enrollees or the provider of record may seek review<br>of determinations by the utilization review agent.The appeal procedure mustprovide for the following:a.On appeal, all determinations not to certify an admission, service, or procedure<br>as being necessary or appropriate must be made by a physician or, if<br>appropriate, a licensed psychologist.Page No. 2b.Utilization review agents shall complete the adjudication of appeals of<br>determinations not to certify admissions, services, and procedures in<br>accordance with 29 U.S.C. 1133 and the timeframes for appeals set forth in 29<br>CFR 2560.503-1.c.Utilization review agents shall provide for an expedited appeals process<br>complying with 29 U.S.C. 1133 and 29 CFR 2560.503-1.5.Utilization review agents shall make staff available by toll-free telephone at least<br>forty hours per week during normal business hours.6.Utilization review agents shall have a telephone system capable of accepting or<br>recording incoming telephone calls during other than normal business hours and<br>shall respond to these calls within two working days.7.Utilization review agents shall comply with all applicable laws to protect<br>confidentiality of individual medical records.8.Psychologists making utilization review determinations shall have current licenses<br>from the state board of psychologist examiners.Physicians making utilizationreview determinations shall have current licenses from the state board of medical<br>examiners.9.When conducting utilization review or making a benefit determination for emergency<br>services:a.A utilization review agent may not deny coverage for emergency services and<br>may not require prior authorization of these services.b.Coverage of emergency services is subject to applicable copayments,<br>coinsurance, and deductibles.10.When an initial appeal to reverse a determination is unsuccessful, a subsequent<br>determination regarding hospital, medical, or other health care services provided or<br>to be provided to a patient which may result in a denial of third-party reimbursement<br>or a denial of precertification for that service must include the evaluation, findings,<br>and concurrence of a physician trained in the relevant specialty to make a final<br>determination that care provided or to be provided was, is, or may be medically<br>inappropriate.However, the commissioner may find that the standards in this section have been met if the<br>utilization review agent has received approval or accreditation by a utilization review accreditation<br>organization.26.1-26.4-04.1.Utilization review in this state - Conditions of employment.Autilization review agent is deemed to be conducting utilization review in this state if the agent<br>conducts utilization review involving services rendered or to be rendered in the state regardless<br>of where the agent actually performs the utilization review. No person may be employed or<br>compensated as a private review agent under any agreement or contract when compensation of<br>the review agent is contingent upon a denial or reduction in the payment for hospital, medical, or<br>other health care services.26.1-26.4-04.2. Utilization review - Duty of health care insurers. A health care insurerthat contracts with another entity to perform utilization review on its behalf remains responsible to<br>ensure that all the requirements of this chapter are met to the same extent the health care<br>insurer would be if it performed the utilization review itself.26.1-26.4-05.Utilization review agent violations - Penalty.Whenever thecommissioner has reason to believe that a utilization review agent subject to this chapter hasPage No. 3been or is engaged in conduct that violates section 26.1-26.4-03 or 26.1-26.4-04, the<br>commissioner shall notify the utilization review agent of the alleged violation. The utilization<br>review agent has thirty days from the date the notice is received to respond to the alleged<br>violation.If the commissioner believes that the utilization review agent has violated this chapter, oris not satisfied that the alleged violation has been corrected, the commissioner shall conduct a<br>hearing on the alleged violation in accordance with chapter 28-32.If, after the hearing, the commissioner determines that the utilization review agent hasengaged in violations of this chapter, the commissioner shall reduce the findings to writing and<br>shall issue and cause to be served upon the utilization review agent a copy of the findings and an<br>order requiring the utilization review agent to cease and desist from engaging in the violations.<br>The commissioner may also, at the commissioner's discretion, order:1.Payment of a penalty of not more than ten thousand dollars for a violation that<br>occurred with such frequency as to indicate a general business practice; or2.Suspension or revocation of the authority to do business in this state as a utilization<br>review agent if the utilization review agent knew that the act was in violation of this<br>chapter.Page No. 4Document Outlinechapter 26.1-26.4 health care service utilization review]]>