See bold text below:
(a) A utilization review program must use documented clinical review criteria that are
(1) based on sound clinical evidence; and
(2) evaluated periodically by a health care insurer’s organizational mechanism specified under 3 AAC 28.906(b)(6) to ensure the program’s effectiveness.
(b) A health care insurer may develop its own clinical review criteria or obtain clinical review criteria from qualified vendors. A health care insurer shall make its clinical review criteria available upon request to government agencies authorized by the director or by law to receive the information.
(c) Qualified health care professionals shall administer the utilization review program and oversee utilization review decisions. A clinical peer shall evaluate the clinical appropriateness of adverse determinations.
(e) A covered person shall be considered to have exhausted the provisions of 3 AAC 28.900 – 3 AAC 28.918 if a health care insurer fails to adhere to the requirements under 3 AAC 28.910 or 3 AAC 28.912 and may
(2) pursue an available remedy under state or federal law on the basis that the health care insurer failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the claim.
(f) Notwithstanding (e) of this section, a covered person may not be considered to have exhausted the provisions of 3 AAC 28.900 – 3 AAC 28.918 if the failure of a health care insurer to adhere to the requirements of 3 AAC 28.910 or 3 AAC 28.912 is a de minimis violation that
(1) does not cause, and is not likely to cause, prejudice or harm to the covered person;
(2) the health care insurer demonstrates was for good cause or due to matters beyond the health care insurer’s control;
(3) occurred in the context of an ongoing, good-faith exchange of information between the health care insurer and the covered person or the covered person’s authorized representative; and
(4) is not a part of a pattern or practice of violations by the health care insurer.
(g) A covered person or the covered person’s authorized representative may request a written explanation of a de minimis violation from a health care insurer. Not later than 10 days after receiving a request, the health care insurer shall
(1) provide a written explanation of the alleged violation; and
(2) the specific reasons for asserting that the violation is de minimis.
(h) A covered person or the covered person’s authorized representative may resubmit and pursue a review of a benefit request or claim under 3 AAC 28.900 – 3 AAC 28.918 or file a grievance under 3 AAC 28.930 / –3 AAC 28.938 if an independent reviewer or a superior court rejects the benefit request or claim for immediate review on the basis that the violation is a de minimis violation under (f) of this section. The time period for re-filing the benefit request or claim under this subsection begins to run when the covered person or the covered person’s authorized representative receives notice of the opportunity to resubmit.
(i) Not later than 10 days after receiving notice from an independent reviewer or a superior court of its rejection of a benefit request or claim for immediate review, a health care insurer shall provide to the covered person or the covered person’s authorized representative notice of the opportunity to resubmit and, as applicable, pursue a review of the benefit request or claim under 3 AAC 28.900 – 3 AAC 28.918.
(j) A health care insurer shall
(1) have procedures in place to ensure that the
(A) health care professionals administering the health care insurer’s utilization review program are applying the clinical review criteria consistently in review determinations; and
(B) appropriate or required individual or individuals are designated to conduct utilization reviews;
(2) routinely assess the effectiveness and efficiency of its utilization review program;
(3) have data systems sufficient to
(A) support utilization review program activities; and
(B) generate management reports to enable the health care insurer to monitor and manage health care services effectively;
(4) maintain adequate oversight over utilization review activity delegated to a utilization review company, which must include
(A) a written description of the utilization review company’s activities and responsibilities, including the company’s reporting requirements;
(B) evidence of the health care insurer’s formal approval of the utilization review company’s program; and
(C) a process by which the health care insurer shall evaluate the utilization review company’s performance;
(5) coordinate the utilization review program with other medical management activity conducted by the health care insurer, such as quality assurance, credentialing, contracting with health care professionals, data reporting, grievance procedures, processes for assessing member satisfaction, and risk management;
(6) provide covered persons and participating providers with access to the health care insurer’s utilization review staff through a toll-free telephone number or other free calling option, and by electronic means; and
(7) when conducting a utilization review,
(A) collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit determination; and
(B) ensure the independence and impartiality of each individual involved in making the utilization review or benefit determination.
(k) A health care insurer may not base one or more of the following decisions related to an individual involved in making a utilization review or benefit determination on the likelihood that the individual will support the denial of benefits:
(4) promotion; or
(5) other similar matter.