Effective – 28 Aug 2019, 3 histories 376.1350. Definitions. — For purposes of sections 376.1350 to 376.1390*, the following terms mean: (1) “Adverse determination”, a determination by a health carrier or a utilization review entity that an admission, availability of care, continued stay or other health care service furnished or proposed to be furnished to […]
Effective – 28 Aug 1997 376.1353. Utilization review activities monitored. — A health carrier shall be responsible for monitoring all utilization review activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of sections 376.1350 to 376.1390 and applicable rules and regulations are met. The health carrier shall […]
Effective – 28 Aug 2019, 2 histories 376.1356. Utilization review entity monitored, when. — Whenever a health carrier contracts to have a utilization review entity perform the utilization review functions required by sections 376.1350 to 376.1390* or applicable rules and regulations, the health carrier shall be responsible for monitoring the activities of the utilization review […]
Effective – 28 Aug 1997 376.1359. Written utilization program implemented, filed with the director. — 1. A health carrier that conducts utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated, for covered services provided. The program document shall describe information as required by the director. 2. […]
Effective – 28 Aug 1997 376.1361. Documented clinical review criteria used in a utilization program — medical director qualifications — compensation of utilization review services. — 1. A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health carrier […]
Effective – 28 Aug 2019, 3 histories 376.1363. Utilization review decisions, procedures. — 1. A health carrier shall maintain written procedures for making utilization review decisions and for notifying enrollees and providers acting on behalf of enrollees of its decisions. For purposes of this section, “enrollee” includes the representative of an enrollee. 2. For determinations, […]
Effective – 28 Aug 2019 376.1364. Unique confirmation number required, prior authorization review — secure electronic transmission for prior authorizations — single cover page, contents. — 1. Any utilization review entity performing prior authorization review shall provide a unique confirmation number to a provider upon receipt from that provider of a request for prior authorization. […]
Effective – 28 Aug 1997 376.1365. Reconsideration of an adverse determination, when. — 1. In a case involving an initial determination or a concurrent review determination, a health carrier shall give the provider rendering the service an opportunity to request on behalf of the enrollee a reconsideration of an adverse determination by the reviewer making […]
Effective – 28 Aug 2018, 2 histories 376.1367. Emergency services benefit determination, coverage required, when. — When conducting utilization review or making a benefit determination for emergency services: (1) A health carrier shall cover emergency services necessary to screen and stabilize an enrollee, as determined by the treating emergency department health care provider, and shall […]
Effective – 28 Aug 1997 376.1369. Certification of compliance, when. — A health carrier shall annually provide a written certification to the director that the utilization review program of the health carrier or its designee complies with all applicable state and federal laws establishing confidentiality and reporting requirements. ——– (L. 1997 H.B. 335)
Effective – 28 Aug 2019, 2 histories 376.1372. Certification and member handbook to include utilization review procedures — website or provider portal, prior authorization requirements available on. — 1. In the certificate of coverage and the member handbook provided to enrollees, a health carrier shall include a clear and comprehensive description of its utilization review […]
Effective – 28 Aug 1997 376.1375. Registry of grievances maintained, procedures — definitions. — 1. A health carrier shall maintain a written register of all grievances in a manner consistent with the requirements for maintaining complaint records pursuant to section 354.445. The grievance register shall contain the total number, type, nature and result of all […]
Effective – 28 Aug 1997 376.1378. Grievances and certificate of compliance filed with the director, when. — 1. A copy of the grievance procedures, including all forms used to process a grievance, shall be filed with the director. Any subsequent material modifications to the documents also shall be filed. In addition, a health carrier shall […]
Effective – 28 Aug 1997 376.1382. First- and second-level grievance review for managed care plans, first-level procedures. — 1. A health carrier that offers managed care plans shall establish a first-level and second-level grievance review process for its managed care plans. A grievance may be submitted by an enrollee, an enrollee’s representative or a provider […]
Effective – 28 Aug 2019, 2 histories 376.1385. Second-level review procedures. — 1. Upon receipt of a request for second-level review, a health carrier shall submit the grievance to a grievance advisory panel consisting of: (1) Other enrollees; and (2) Representatives of the health carrier that were not involved in the circumstances giving rise to […]
Effective – 28 Aug 1997 376.1387. Appeals of grievances determined by the director. — 1. The director shall resolve any grievance regarding an adverse determination as to covered services appealed by an enrollee or health carrier or plan sponsor through any means not specifically prohibited by law but if the grievance is unresolved by the […]
Effective – 28 Aug 1997 376.1389. Expedited grievance review procedure. — 1. A health carrier shall establish written procedures for the expedited review of a grievance involving a situation where the time frame of the standard grievance procedures set forth in sections 376.1382 and 376.1385 would seriously jeopardize the life or health of an enrollee […]
