58-17H UTILIZATION REVIEW AND BENEFIT DETERMINATIONS
UTILIZATION REVIEW AND BENEFIT DETERMINATIONS
Health benefit plan defined.
Urgent care request defined.
Applicability of chapter.
Health carrier to provide emergency services coverage without requiring prior
authorization--Standards for coverage of emergency services.
In-network emergency services.
Cost-sharing requirements for out-of-network emergency services.
Cost-sharing requirements for covered persons--Payments to out-of-network
Exceptions for payments by capitated and other plans without negotiated fees.
Negotiated amounts for in-network providers for a particular emergency service.
General cost-sharing requirements allowed.
Access to representative for post-evaluation or post-stabilization services.
Health carrier may be deemed to meet emergency medical coverage requirements if
met by private accrediting body.
Health carrier responsibility for utilization review activities.
Director to hold health carrier responsible for utilization review performance of
Written utilization review program required--Contents of program document.
Utilization review program to use documented clinical review criteria--Criteria to be
available to authorized agencies upon request.
Program to be administered by qualified licensed health care professionals.
Determinations to be issued in timely manner--Process to ensure consistency.
Effectiveness and efficiency of program to be routinely reviewed.
Data systems to support program activities and generate management reports.
Health carrier oversight of delegated activities--Requirements.
Utilization review to be coordinated with other medical management activity of
Health carrier to provide free access to review staff.
Only information necessary for review or determination to be collected.
Independence and impartiality required for utilization review.
Written procedures required for making determinations--Notification.
Prospective review determinations--Timing--Notification of requirements--Extension
Concurrent review determinations--Timing--Notification requirements.
Retrospective review determinations--Timing--Notification requirements.
Calculation of time period for determination for prospective and retrospective
Notification of adverse determination--Contents.
Information required to be provided to covered persons and prospective covered
Health carrier may be deemed to meet utilization review requirements if met by
private accrediting body.
Registration of utilization review organizations--Required information.
Filing changes in registration information.
Requests for information from utilization review organizations.
Activities of nonregistered utilization review organizations prohibited.
Registration fee for utilization review organizations.
Urgent care requests--Written procedures required for receipt and determination of
Insufficient information for determination--Notice and statement of necessary
Insufficient information for determination of prospective urgent care requests.
Urgent care requests--Timely notification of determination.
Time within which to submit necessary information.
Urgent care requests--Notice of determination--Failure to submit necessary
information as grounds for denial of certification.
Concurrent review urgent care requests--Extended care requests--Time for
determination and notice.
Calculation of time periods for determination.
Notification of adverse determination--Requirements.
Promulgation of rules.