420-E:1 Definitions. – In this chapter: I. "Commissioner" means the insurance commissioner. I-a. " Claim involving urgent care " means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations: (a) Could seriously jeopardize the life or health of the claimant or […]
420-E:2 Licensure or Registration Required. – I. Any person, partnership or corporation, other than an insurer, nonprofit service organization, health maintenance organization, or an employee of those exempt organizations, that performs medical utilization review services on behalf of commercial insurers, nonprofit service organizations, health maintenance organizations, third-party administrators or employers, shall apply for a […]
420-E:2-a Medical Director. – Every medical utilization review entity licensed by the department under this chapter shall employ a medical director licensed under RSA 329 or, in the case of a dental utilization review entity, a dentist licensed under RSA 317-A. Source. 2000, 18:3. 2004, 187:5, eff. July 31, 2004.
420-E:3 Information Required. – I. Each person, partnership or corporation licensed under this chapter shall, at the time of initial licensure and on or before April 1 of each succeeding year, provide the department with the following information: (a) The process used by the entity to carry out its utilization review services, including the […]
420-E:4 Minimum Standards; Licensure of Medical Utilization Review Entities. – All licensees shall establish and maintain a utilization review procedure by which a claimant or claimant’s representative may seek a claim benefit determination. The procedure shall meet the following minimum standards: I. The licensee shall maintain a toll-free telephone number to ensure that a […]
420-E:4-a Uniform Prior Authorization Forms and Electronic Standard for Prescription Drug Benefits. – I. Beginning July 1, 2017, all health insurers, health maintenance organizations, health services corporations, medical services corporations, and preferred provider programs may, when requiring prior authorization for a prescription drug, use and accept the prior authorization paper forms or electronic standard […]
420-E:5 Listing. – The commissioner shall compile and maintain a current listing of persons, partnerships or corporations licensed pursuant to this chapter. The list shall be available to the public. Source. 1992, 142:2, eff. July 5, 1992.
420-E:6 Periodic Reviews. – The commissioner or designee may conduct periodic reviews of the operations of the entities licensed under this chapter to ensure that they continue to meet the minimum standards set in RSA 420-E:4 and any applicable rules adopted by the commissioner. The commissioner may perform periodic telephone audits of licensees to […]
420-E:7 Rulemaking. – The commissioner shall adopt rules, under RSA 541-A and after public hearing, relative to: I. Procedures for application for license under RSA 420-E:2. II. Initial application fees and annual license fees. III. The time period for notification of determination as required under RSA 420-E:4, IV. IV. Standards for telephone accessibility as […]
420-E:8 Enforcement; Administrative Fine; Hearings. – I. The commissioner may take appropriate action against a licensee which fails to meet the standards under this chapter or any rules adopted by the commissioner, or who fails to respond in a timely manner to corrective actions ordered by the commissioner. The commissioner may impose an administrative […]
420-E:9 Rulings on Appropriateness of Medical Judgments Not Authorized. – Nothing in this chapter requires or authorizes the commissioner to rule on the appropriateness of medical decisions or judgments rendered by review entities and their agents. Source. 1992, 142:2, eff. July 5, 1992.