The purpose of this subchapter is to: (1) Promote the delivery of quality health care in a cost-effective manner; (2) Foster greater coordination between payors and providers conducting utilization review activities; (3) Protect patients, business, and providers by ensuring that private review agents are qualified to perform utilization activities and to make informed decisions on […]
As used in this subchapter: (1) [Repealed.] (2) “Certificate” means a certificate of registration granted by the State Board of Health to a private review agent; (3) (A) “Private review agent” means a nonhospital-affiliated person or entity performing utilization review on behalf of: (i) An employer of employees in the State of Arkansas; or (ii) […]
A private review agent who approves or denies payment or who recommends approval or denial of payment for hospital or medical services or whose review results in approval or denial of payment for hospital or medical services on a case-by-case basis may not conduct utilization review in this state unless the State Board of Health […]
(a) The State Board of Health may waive the requirements of this subchapter for the activities of a private review agent in connection with a contract with the United States Government for utilization review of patients eligible for hospital and medical services under the Social Security Act. (b) No certificate is required for those private […]
(a) A person who violates any provision of this subchapter or any rule adopted under this subchapter shall be guilty of a violation and upon conviction shall be subject to a penalty not exceeding one thousand dollars ($1,000). (b) Each day that a violation is continued after the first conviction is a separate offense.
(a) (1) In accordance with the Arkansas Administrative Procedure Act, § 25-15-201 et seq., the State Board of Health shall adopt rules to implement this subchapter. (2) Rules governing utilization review plans under this subchapter shall impose no greater requirements than those required for utilization review activities for state-certified health maintenance organizations under the laws […]
(a) (1) Every health insurance plan proposing to issue or deliver a health insurance policy or contract or administer a health benefit program which provides for the coverage of hospital and medical benefits and the utilization review of those benefits shall: (A) Have a certificate in accordance with this subchapter; or (B) Contract with a […]
(a) An applicant for a certificate shall: (1) Submit an application to the State Board of Health; and (2) Pay to the board the application fee established by the board by rule. (b) The application shall: (1) Be on a form and accompanied by any supporting documentation that the board requires; and (2) Be signed […]
In conjunction with the application, the private review agent shall submit information that the State Board of Health requires, including: (1) A utilization review plan that includes: (A) A description of review standards and procedures to be used in evaluating proposed or delivered hospital and medical care; and (B) The provisions by which patients, physicians, […]
(a) A certificate expires on the second anniversary of its effective date unless the certificate is renewed for a two-year term as provided in this section. (b) Before the certificate expires, a certificate may be renewed for an additional two-year term if the applicant: (1) Otherwise is entitled to the certificate; (2) Pays the State […]
(a) The State Board of Health may revoke or deny a certificate if the holder does not comply with performance assurances under this section, violates any provision of this subchapter, or violates any rule adopted pursuant to this subchapter. (b) The board shall deny a certificate to any applicant if upon review of the application […]
(a) (1) Before denying or revoking a certificate under this subchapter, the State Board of Health shall provide the applicant or certificate holder with reasonable time to supply additional information demonstrating compliance with the requirements of this subchapter and the opportunity to request a hearing. (2) If an applicant or certificate holder requests a hearing, […]
A private review agent may not disclose or publish individual medical records or any other confidential medical information obtained in the performance of utilization review activities without the appropriate procedures for protecting the patient’s confidentiality. However, nothing in this subchapter shall prohibit private review agents from providing patient information to a third party whom the […]
Nothing in this subchapter shall be deemed to reduce or expand the liability of any person or entity for any actions or activities with respect to utilization review.
