20-2530. Definitions For the purposes of this article: 1. " Member" means a person who is covered under a health care plan provided by a health care insurer or that person’s treating provider, parent, legal guardian, surrogate who is authorized to make health care decisions for that person by a power of attorney, a court […]
20-2531. Applicability; requirements; exception A. Notwithstanding article 1 of this chapter and subject to subsection B of this section, this article applies to all utilization review decisions made by utilization review agents and health care insurers operating in this state. B. Each utilization review agent and each health care insurer operating in this state whose […]
20-2532. Utilization review standards and criteria; requirements A. Each utilization review agent shall: 1. Adopt a written utilization review plan with standards and criteria that apply to all utilization review decisions and that are objective, clinically valid and compatible with established principles of health care. 2. Establish the utilization review plan with input from physician […]
20-2533. Denial; levels of review; disclosure; additional time after service by mail; review process A. Any member who is denied a covered service or whose claim for a service is denied may pursue the applicable review process prescribed in this article. Except as provided in sections 20-2534 and 20-2535, health care insurers shall provide at […]
20-2534. Expedited medical review; expedited appeal A. Any member who is denied a request for a covered service may pursue an expedited medical review of that denial if the member’s treating provider certifies in writing and provides supporting documentation to the utilization review agent that the time period for the informal reconsideration process and formal […]
20-2535. Informal reconsideration A. Any member who is denied a service and who does not qualify for an expedited medical review pursuant to section 20-2534 may request, either orally or in writing, an informal reconsideration of that denial by notifying the person described in section 20-2533, subsection C, paragraph 3. After the denial, the member […]
20-2536. Formal appeal A. After any applicable informal reconsideration pursuant to section 20-2535, if the utilization review agent denies the member’s request for a covered service, the member may appeal that adverse decision. The member shall send a written appeal to the utilization review agent within sixty days after receipt of the adverse decision. In […]
20-2537. External independent review; expedited external independent review (Conditionally Rpld.) A. If the utilization review agent denies the member’s request for a covered service or claim for a covered service at both the informal reconsideration level and the formal appeal level, or at the expedited medical review level, the member may initiate an external independent […]
20-2538. Independent review organizations A. Pursuant to title 41, chapter 23, the director shall procure as many independent review organizations as necessary and practicable to perform the independent medical reviews described in section 20-2537. B. Through the procurement process the director shall ensure that any procured independent review organization uses physicians or other health care […]
20-2539. Rules The director may adopt rules pursuant to title 41, chapter 6 to carry out this article.
20-2540. Health care appeals fund A. The health care appeals fund is established consisting of monies collected pursuant to subsection B of this section. The fund is a special state fund pursuant to section 35-142, subsection A, paragraph 8. Monies in the fund do not revert to the state general fund. The department shall administer […]
20-2541. Health care insurer fee The director may assess each health care insurer that is authorized to transact insurance: 1. A single fee of not more than $200 per insurer. 2. Up to $200 each year for the costs of performing the responsibilities relating to the procurement of independent review organizations as prescribed in sections […]
