56-6-705 - Utilization review agents Minimum standards.
56-6-705. Utilization review agents Minimum standards.
(a) All utilization review agents shall meet the following minimum standards:
(1) Notification of a determination by the utilization review agent shall be mailed or otherwise communicated to the provider of record or the enrollee or other appropriate individual within two (2) business days of the receipt of the request for determination and the receipt of all information necessary to complete the review;
(2) Any determination by a utilization review agent as to the necessity or appropriateness of an admission, service, or procedure shall be reviewed by a physician or determined in accordance with standards or guidelines approved by a physician;
(3) Any notification of determination not to certify an admission or service or procedure must include the principal reason for the determination and the procedures to initiate an appeal of the determination;
(4) Utilization review agents shall maintain and make available a written description of the appeal procedure by which the enrollee or the provider of record may seek review of a determination by the utilization review agent. The appeal procedure shall provide for the following:
(A) On appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate shall be made by a physician in the same or a similar general specialty as typically manages the medical condition, procedure or treatment under discussion as mutually deemed appropriate. For mental health and chemical dependency care, the person performing the utilization review in these appeal determinations must be both licensed at the independent practice level and in an appropriate mental health or chemical dependency discipline like that of the provider seeking authorization for the care denied;
(B) Utilization review agents shall complete the adjudication of appeals of determinations not to certify admissions, services, and procedures no later than thirty (30) days from the date the appeal is filed and the receipt of all information necessary to complete the appeal; and
(C) When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination over the telephone on an expedited basis. A representative of a hospital or other health care provider or a representative of the enrollee or covered patient may assist in an appeal. Utilization review agents shall complete the adjudication on an expedited basis. Utilization review agents shall complete the adjudication of expedited appeals within forty-eight (48) hours of the date the appeal is filed and the receipt of all information necessary to complete the appeal. Expedited appeals which do not resolve a difference of opinion may be resubmitted through the standard appeal process;
(5) Utilization review agents shall make staff available by toll-free telephone at least forty (40) hours per week during normal business hours;
(6) Utilization review agents shall have a telephone system capable of accepting or recording incoming telephone calls during other than normal business hours and shall respond to these calls within two (2) working days;
(7) Utilization review agents shall comply with all applicable laws to protect the confidentiality of individual medical records;
(8) Physicians or psychologists making utilization review determinations shall have current licenses from a state licensing agency in the United States;
(9) Utilization review agents shall allow a minimum of twenty-four (24) hours after an emergency admission, service, or procedure for an enrollee or the enrollee's representative to notify the utilization review agent and request certification or continuing treatment for that condition; and
(10) (A) For outpatient mental health and chemical dependency care, the patient must register pursuant to the requirements of the policy or contract. After registration, the patient shall be approved for at least twelve (12) visits to a particular provider, except as otherwise provided in this section;
(B) Initial utilization review for such outpatient mental health or chemical dependency patients shall be limited to no more than a two (2) page form to be submitted via facsimile or internet and pursuant to state and federal privacy rules, security rules, and any final rules issued pursuant to the Health Insurance Portability and Accountability Act (HIPAA). After November 1, 2005, or sooner if required by HIPAA, the form shall be restricted to a single page. After November 1, 2005, the provider may no longer fax the form but is required to use the internet to submit necessary information if the utilization review agent so requires. In the event that the utilization review agent elects to restrict the submissions to the internet, provisions must be made to fax the information in the event of computer malfunction;
(C) After the initial utilization review, additional information or follow-up utilization review shall be limited to no more than eighteen percent (18%) of the total number of mental health and chemical dependency patients' reviews performed by the utilization review agent for the previous year adjusted for the difference of covered lives in this state for the present calendar year or as otherwise required by the utilization review accreditation commission (URAC). The eighteen-percent limit shall not apply to utilization review applicable to at risk populations, patients seen more than two (2) visits a week and patients for which substance abuse is reported or suspected. Calls from reviews to providers for appointment follow-up calls or for the credentialing process shall also not be subject to the eighteen-percent limit;
(D) After utilization review as provided in this subdivision (a)(10), patients shall be authorized for at least twelve (12) additional visits or as otherwise recommended by the treatment plan;
(E) Nothing in this part shall be construed to require compliance with the final security and privacy rules of HIPAA prior to the compliance dates set by the secretary of health and human services; and
(F) Nothing in this part shall affect the policy or contract benefits nor shall it affect the Mental Health Parity Act, compiled in §§ 56-7-2601 and 56-7-2360.
(b) The commissioner shall exempt from these standards any utilization review agent who has received accreditation by URAC or the national committee for quality assurance.
[Acts 1992, ch. 812, § 6; 2002, ch. 799, §§ 4, 5; 2007, ch. 287, §§ 1, 2; 2008, ch. 812, § 1.]