Definitions; Requirements for Utilization Review.
See the bold text below:
Section 120-2-58-.02. Definitions
(1) “Active Practice” means activities including, but not limited to, the review of medical records and charts, participation in utilization review and medical management, evaluating medical necessity, monitoring patient therapy, graduate medical education, or maintenance of board certification.
(2) “Adverse Determination” means a determination based on medical necessity made by a private review agent or utilization review entity not to grant authorization to a hospital, surgical or other facility admission, extension of a hospital stay or other health care service or procedure based on medical necessity or appropriateness.
(3) “Appeal” means a formal request, either orally, or in writing or by electronic transmission, to a private review agent to reconsider a determination not to certify an admission, extension of stay, or other health care service or procedure.
(4) “Authorization” means a determination by a private review agent or utilization review entity that a healthcare service has been reviewed and, based on the information provided, satisfies the utilization review entity’s requirements for medical necessity.
(5) “Claim Administrator” means any entity that reviews and determines whether to pay claims to covered persons on behalf of the healthcare plan. Such payment determinations are made on the basis of contract provisions including medical necessity and other factors. Claim administrators may be insurers or their designated review organization, self-insured employers, management firms, third-party administrators, or other private contractors.
(6) “Clinical Criteria” means the written policies, decisions, rules, medical protocols, or guidelines used by a private review agent or utilization review entity to determine medical necessity.
(7) “Clinical Peer” means a healthcare provider who is licensed without restriction or otherwise legally authorized and currently in active practice in the same or similar specialty as that of the treating provider, and who typically manages the medical condition or disease at issue and has knowledge of and experience providing the healthcare service or treatment under review.
(8) “Complaint” is a communication either orally, in writing or by electronic transmission concerning matters related to utilization review including, but not limited to, health care services, denials, accessibility, and confidentiality.
(9) “Concurrent Review” means utilization review conducted during a patient’s hospital stay or course of treatment.
(10) “Covered Person” means an individual, including, but not limited to, any subscriber, enrollee, member, beneficiary, participant, or his or her dependent, eligible to receive healthcare benefits by a health insurer pursuant to a healthcare plan or other health insurance coverage.
(11) “Emergency healthcare services” means healthcare services rendered after the recent onset of a medical or traumatic condition, sickness, or injury exhibiting acute symptoms of sufficient severity, including, but not limited to, severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in:
(A) Placing the patient’s health in serious jeopardy;
(B) Serious impairment to bodily functions; or
(C) Serious dysfunction of any bodily organ or part.
(12) “Facility” means a hospital, ambulatory surgical center, birthing center, diagnostic and treatment center, hospice, or similar institution. Such term shall not mean a healthcare provider’s office.
(13) “Health insurer” or “insurer” means an accident and sickness insurer, care management organization, healthcare corporation, health maintenance organization provider sponsored healthcare corporation, or any similar entity regulated by the Commissioner.
(14) “Healthcare plan” means any hospital or medical insurance policy or certificate, qualified higher deductible health plan, stand-alone dental plan, health maintenance organization or other managed care subscriber contract, the state health benefit plan, or any plan entered into by a care management organization as permitted by the Department of Community Health for the delivery of healthcare services.
(15) “Healthcare service” means healthcare procedures, treatments, or services provided by a facility licensed in this state or provided within the scope of practice of a doctor of medicine, a doctor of osteopathy, or another healthcare provider licensed in this state. Such term includes but is not limited to the provision of pharmaceutical products or services or durable medical equipment.
(16) “Medical necessity” or “medically necessary” means healthcare services that a prudent physician or other healthcare provider would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or disease or its symptoms in a manner that is:
(A) In accordance with generally accepted standards of medical or other healthcare practice;
(B) Clinically appropriate in terms of type, frequency, extent, site, and duration;
(C) Not primarily for the economic benefit of the health insurer or for the convenience of the patient, treating physician, or other healthcare provider; and
(D) Not primarily custodial care, unless custodial care is a covered service or benefit under the covered person’s healthcare plan.
(17) “Pharmacy benefits manager” means a person, business entity, or other entity that performs pharmacy benefits management. Such term includes a person or entity acting for a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management for a healthcare plan. Such term shall not include services provided by pharmacies operating under a hospital pharmacy license. Such term shall not include health systems while providing pharmacy services for their patients, employees, or beneficiaries, for indigent care, or for the provision of drugs for outpatient procedures. Such term shall not include services provided by pharmacies affiliated with a facility licensed under Code Section 31-44-4 or a licensed group model health maintenance organization with an exclusive medical group contract and which operates its own pharmacies which are licensed under Code Section 26-4-110.
(18) “Prior authorization” means any written or oral determination made at any time by a claim administrator or an insurer, or any agent thereof, that a covered person’s receipt of healthcare services is a covered benefit under the applicable plan and that any requirement of medical necessity or other requirements imposed by such plan as prerequisites for payment for such services have been satisfied. The term ‘agent’ as used in this paragraph shall not include an agent or agency as defined in Code Section 33-23-1.
(19) “Private review agent” means any person or entity which performs utilization review for:
(A) An employer with employees who are treated by a health care healthcare provider in this state;
(B) An insurer; or
(C) A claim administrator.
(20) “Reconsideration” means a request either orally, in writing or by electronic transmission to the private review agent to reconsider an adverse determination.
(21) “Review Criteria” means the written policies, decisions, rules, medical protocols or guidelines used by the private review agent to determine medical necessity or appropriateness.
(22) “Urgent healthcare service” means a healthcare service with respect to which the application of the time periods for making a non-expedited prior authorization, which, in the opinion of a physician or other healthcare provider with knowledge of the covered person’s medical condition:
(A) Could seriously jeopardize the life or health of the covered person or the ability of such person to regain maximum function; or
(B) Could subject the covered person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review. Such term shall include services provided for the treatment of substance use disorders which otherwise qualify as an urgent healthcare service.
(23) “Utilization review entity” means an insurer or other entity that performs prior authorization for one or more of the following entities:
(A) An insurer that writes health insurance policies;
(B) A preferred provider organization or health maintenance organization; or
(C) Any other individual or entity that provides, offers to provide, or administers hospital, outpatient, medical, behavioral health, prescription drug, or other health benefits to a person treated by a healthcare provider in this state under a health insurance policy, plan, or contract.
(24) “Utilization Review Determination” means a recommendation by a private review agent regarding medical necessity or appropriateness of the health care services given or proposed to be given to a patient.
Section 120-2-58-.05. Requirements for Utilization Review
(1) Private review agents shall have sufficient staff to facilitate review in accordance with review criteria and shall designate one or more individuals able to effectively communicate medical and clinical information.
(2) Private review agent shall provide access to its review staff by a toll free or collect call telephone line during normal business hours. A private review agent shall have an established procedure to review timely call backs from health care providers and shall establish written procedures for receiving after-hour calls, either in person or by recording.
(3) Private review agent shall collect only the information necessary to certify the admission, procedure or treatment, length of stay, frequency and duration of services. All requests for information shall be made during normal business hours.
(4) Private review agents shall identify themselves prior to collecting necessary information.
(5) Private review agents shall establish and follow procedures and rules for on-site medical facility review.
(6) In the event a private review agent questions the medical necessity or appropriateness of care, the following procedures will apply:
(a) The attending health care provider shall have the opportunity to discuss a utilization review determination promptly by telephone with a clinical peer, an identified health care provider representing the private review agent and trained in a related healthcare specialty. If the determination is made not to certify, an adverse determination exists.
(b) Reconsideration of an adverse determination occurs when any questions concerning medical necessity or appropriateness of care are not resolved under subparagraph (a) above. The right to appeal an adverse determination shall be available to the enrollee and the attending physician or other ordering health care provider. The enrollee or enrollee’s representative shall be allowed a second review by another identified health care provider in an appropriate medical specialty who represents the private review agent.
(7) The private review agent shall have written procedures for providing notification of its determinations regarding all forms of certification in accordance with the following:
State Medical Necessity Decisions-Deadlines
(a) When an initial determination is made to certify, notification shall be provided promptly either by telephone, in writing or electronic transmission to the attending health care provider, the facility rendering service as well as to the enrollee. Written notification shall be transmitted within two (2) business days of the determination.
(b) When a determination is made not to certify, the attending physician and/or other ordering health care provider or facility rendering service shall:
1. Be notified by telephone within one (1) business day.
2. Be sent a written notification within one (1) business day, which also shall be sent to the enrollee. The written notification shall include principal reason(s) for the determination and instructions for initiating an appeal of the adverse determination.
State Medical Necessity Appeals-Deadlines
(c) The private review agent shall establish procedures for appeals to be made in writing and by telephone. The private review agent shall notify the health care provider and enrollee in writing of its determination on the appeal as soon as possible, but in no case later than sixty (60) days after receiving the required documentation to conduct the appeal.
(d) The appeals procedure does not preclude the right of an enrollee to pursue legal action.