20-2501. Definitions; scope A. In this chapter, unless the context otherwise requires: 1. " Adverse decision" means a utilization review determination by the utilization review agent that a requested service or claim for service is not a covered service or is not medically necessary under the plan if that determination results in a documented denial […]
20-2502. Utilization review activities; exemptions A. A utilization review agent shall not conduct utilization review in this state unless the utilization review agent meets or is exempt from this article. B. A person is exempt from sections 20-2504, 20-2505, 20-2506, 20-2507 and 20-2508 and section 20-2509, subsection A if the person: 1. Is accredited by […]
20-2503. Utilization review standards; applicability; definition A. The utilization review standards established in this chapter apply to prospective, concurrent and retrospective utilization review for: 1. Inpatient admissions to hospitals and other inpatient facilities. 2. Outpatient admissions to surgical facilities. 3. Outpatient surgical services provided in a health care provider’s office. 4. Medical, surgical and health […]
20-2504. Utilization review agents; certification; rules A. The director shall issue a certificate to a utilization review agent that meets all of the requirements of this chapter and all applicable rules. A utilization review agent shall submit a signed and notarized application on a form prescribed by the director. B. A certificate is not transferable. […]
20-2505. Application for certification A utilization review agent applying for a certificate shall submit the following information to the department: 1. A signed and notarized application on a form prescribed by the director. 2. A utilization review plan that includes a summary description of review guidelines, protocols and procedures, standards and criteria to be used […]
20-2506. Certification; responsibilities of department; cost recovery A. The director shall examine the affairs, transactions, accounts and records of each utilization review agent before issuing an initial certificate and as often as the director deems it necessary in order to determine if a utilization review agent is in compliance with this chapter. The department shall […]
20-2507. Certificates; renewal A. A certificate expires on the third anniversary of its effective date unless the certificate is renewed for a three year term as provided in this section. B. A certificate holder may renew an unexpired certificate for an additional three year term if the certificate holder meets the requirements of this chapter.
20-2508. Denial, suspension or revocation of certificates; hearing; civil penalties A. The director shall deny a certificate if the director finds that the utilization review agent does not: 1. Have an allopathic or osteopathic physician available to supervise utilization review activities of any medical, surgical or health care services except that: (a) A dental service […]
20-2509. Confidentiality A. A utilization review agent shall file with the director written procedures for assuring that patient information it obtains during the process of utilization review is maintained as confidential in accordance with applicable federal and state laws, is used solely for the purposes of utilization review, quality assurance, discharge planning and catastrophic case […]
20-2510. Health care insurers requirements; medical directors A. A health care insurer that proposes to provide coverage of inpatient hospital and medical benefits, outpatient surgical benefits or any medical, surgical or health care service for residents of this state with utilization review of those benefits shall meet at least one of the following requirements: 1. […]
20-2511. Violation; injunctive relief If the director believes that a utilization review agent is violating or is about to violate section 20-2502, the director may order the agent to cease and desist. The director through the attorney general may file a complaint in the superior court in the county in which the agent transacts utilization […]
