In conjunction with the application, the private review agent shall submit information that the department requires including:
A utilization review plan that includes a description of review criteria, standards and procedures to be used in evaluating proposed or delivered hospital and medical care and the provisions by which patients, physicians or hospitals may seek reconsideration or appeal of adverse decisions by the private review agent;
The type and qualifications of the personnel either employed or under contract to perform the utilization review;
The procedures and policies to insure that a representative of the private review agent is reasonably accessible to patients and providers at all times in this state;
The policies and procedures to insure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed;
A copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan; and
A list of the third party payors for which the private review agent is performing utilization review in this state.