Section 27-18.9-12. – Variance of statutory requirements.
§ 27-18.9-12. Variance of statutory requirements. Statutory variances shall be issued for a period not to exceed one year and may be subject to such terms and conditions deemed necessary as determined by the commissioner. Prior to issuing a statutory variance, the office may provide notice and public hearing to ensure necessary beneficiary and healthcare […]
Section 27-18.9-13. – Denial, suspension, or revocation of certificate — Penalties.
§ 27-18.9-13. Denial, suspension, or revocation of certificate — Penalties. Adopted pursuant to this chapter; (a) The office may deny a certificate or certification upon review of the application if, upon review of the application, it finds that the applicant proposing to conduct utilization review does not meet the standards required by this chapter or […]
Section 27-18.9-14. – Penalties and enforcement.
§ 27-18.9-14. Penalties and enforcement. For the purposes of this chapter, in addition to the provisions of § 27-18.9-13, a healthcare entity and/or review agent or any person or entity conducting any activities requiring certification under this chapter shall be subject to the penalty and enforcement provisions of title 27 and chapters 14 and 14.5 […]
Section 27-18.9-15. – Severability.
§ 27-18.9-15. Severability. If any provision of this chapter or the application of any provision to any person or circumstance shall be held invalid, that invalidity shall not affect the provisions or application of this chapter which can be given effect without the invalid provision or application, and to this end the provisions of this […]
Section 27-18.9-6. – Non-administrative benefit determination notifications.
§ 27-18.9-6. Non-administrative benefit determination notifications. (a) Benefit determination notification timelines. A healthcare entity and/or its review agent shall comply with the following: (1) For urgent or emergent healthcare services, benefit determinations (adverse or non-adverse) shall be made as soon as possible taking into account exigencies but not later than 72 hours after receipt of […]
Section 27-18.9-7. – Internal appeal procedural requirements.
§ 27-18.9-7. Internal appeal procedural requirements. (a) Administrative and non-administrative appeals. The review agent shall conform to the following for the internal appeal of administrative or non-administrative, adverse benefit determinations: (1) The review agent shall maintain and make available a written description of its appeal procedures by which either the beneficiary or the provider of […]
Section 27-18.9-8. – External appeal procedural requirements.
§ 27-18.9-8. External appeal procedural requirements. (a) General requirements. (1) In cases where the non-administrative, adverse benefit determination or the final internal level of appeal to reverse a non-administrative, adverse benefit determination is unsuccessful, the healthcare entity or review agent shall provide for an external appeal by an independent review organization (IRO) approved by the […]
Section 27-18.9-9. – Reporting requirements.
§ 27-18.9-9. Reporting requirements. The office shall establish reporting requirements to determine if adverse benefit determination and/or utilization review programs are in compliance with the provisions of this chapter and applicable regulations as well as in compliance with applicable federal law. History of Section.P.L. 2017, ch. 302, art. 5, § 5.
Section 27-18.9-10. – Rules and regulations.
§ 27-18.9-10. Rules and regulations. The health insurance commissioner may promulgate such rules and regulations as are necessary and proper to effectuate the purpose and for the efficient administration and enforcement of this chapter. History of Section.P.L. 2017, ch. 302, art. 5, § 5.
Section 27-18.9-11. – Waiver of requirements.
§ 27-18.9-11. Waiver of requirements. (a) The office shall waive the requirements of this chapter only when a conflict exists with those activities of a review agent that are conducted pursuant to contracts with the state or the federal government or those activities under other state or federal jurisdictions. (b) The office shall waive de […]