Minimum utilization review agent requirements
A utilization review agent must satisfy the following minimum requirements:
(1) Provide toll free telephone access at least forty (40) hours each week during normal business hours.
(2) Maintain a telephone call recording system capable of accepting or recording incoming telephone calls or providing instructions during hours other than normal business hours.
(3) Respond to each telephone call left on the recording system maintained under subdivision (2) within two (2) business days after receiving the call.
(4) Protect the confidentiality of the medical records of covered individuals.
(5) Within two (2) business days after receiving a request for a utilization review determination that includes all information necessary to complete the utilization review determination, notify the enrollee or the provider of record of the utilization review determination by mail or another means of communication.
(6) Include in the notification of a utilization review determination not to certify an admission, a service, or a procedure:
(A) If the determination not to certify is based on medical necessity or appropriateness of the admission, service, or procedure, the principal reason for that determination; and
(B) The procedures to initiate an appeal of the determination.
(7) Ensure that every utilization review determination as to the necessity or appropriateness of an admission, a service, or a procedure is:
(A) Reviewed by a physician; or
(B) Determined in accordance with standards or guidelines approved by a physician.
(8) Ensure that every physician making a utilization review determination for the utilization review agent has a current license issued by a state licensing agency in the United States.
(9) Provide a period of at least forty-eight (48) hours following an emergency admission, service, or procedure during which:
(A) An enrollee; or
(B) The representative of an enrollee;
may notify the utilization review agent and request certification or continuing treatment for the condition involved in the admission, service, or procedure.
(10) Provide an appeals procedure satisfying the requirements set forth in section 12 of this chapter.
(11) Develop a utilization review plan and file a summary of the plan with the department.