§ 56-6-701. Short Title
This part shall be known and may be cited as the “Health Care Service Utilization Review Act.”
§ 56-6-702. Purpose
The purpose of this part is to: Promote the delivery of quality health care in a cost-effective manner; Assure that utilization review agents adhere to reasonable standards for conducting utilization review; Foster greater coordination and cooperation between health care providers and utilization review agents; Improve communications and knowledge of benefit plan requirements among all parties […]
§ 56-6-703. Part Definitions
As used in this part, unless the context otherwise requires: “Adverse determination” has the same meaning as defined in § 56-61-102; “Clinical criteria” means the written policies, screening procedures, decision rules, decision abstracts, clinical protocols, practice guidelines, and medical protocols used by the utilization review agent to determine the necessity and appropriateness of health care […]
§ 56-6-704. Utilization Review Agents
Utilization review agents shall adhere to the minimum standards set forth in § 56-6-705. Utilization review programs for the mental health and chemical dependency care must comply with the most recent requirements of nationally recognized utilization review accrediting bodies, i.e., the utilization review accreditation commission (URAC) and the national committee for quality assurance (NCQA), if […]
§ 56-6-705. Utilization Review Agents — Minimum Standards
All utilization review agents shall meet the following minimum standards: 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 […]
§ 56-6-706. Violations
Whenever the commissioner has reason to believe that a utilization review agent subject to this part has been or is engaged in conduct that violates this part, the commissioner shall notify the utilization review agent of the alleged violation. The utilization review agent has thirty (30) days from the date the notice is received to […]