Minimum Standards; Licensure of Medical Utilization Review Entities
See bold sections below:
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 representative of the licensee shall be accessible by telephone to insureds, patients, and providers 7 days a week during normal working hours.
II. Claim benefit determinations shall be made by a licensed or certified health care provider.
III. Clinical review criteria considered or utilized in making claim benefit determinations shall be:
(a) Developed with input from appropriate actively practicing practitioners in the carrier or other licensed entity’s service area;
(b) Updated at least biennially and as new treatments, applications, and technologies emerge;
(c) Developed in accordance with the standards of national accreditation entities:
(d) Based on current, nationally accepted standards of medical practice; and
(e) If practicable, evidence-based.
IV. Notification of claim benefit determinations shall be made within the following time periods:
Medical Necessity Decisions-Deadlines
(a) The determination of a claim involving urgent care shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 72 hours after receipt of the claim, unless the claimant or claimant’s representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable. In the case of such failure, the licensee shall notify the claimant or claimant’s representative within 24 hours of receipt of the claim and shall advise the claimant or claimant’s representative of the specific information necessary to determine the claim. The claimant or claimant’s representative shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. Thereafter, notification of the benefit determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of (1) the licensee’s receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant’s representative to provide the specified additional information.
(b) The determination of a claim involving urgent care and relating to the extension of an ongoing course of treatment and involving a question of medical necessity shall be made within 24 hours of receipt of the claim; provided, that the claim is made at least 24 hours prior to the expiration of the prescribed period of time or course of treatment.
(c) The determination of all other claims for preservice benefits shall be made within a reasonable time period appropriate to the medical circumstances, but in no event more than 15 days after receipt of the claim. This period may be extended one time by the licensee for up to 15 days; provided, that the licensee both determines that such an extension is necessary due to matters beyond the control of the licensee and notifies the claimant or claimant’s representative, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which the licensee expects to render a decision. If such an extension is necessary due to a failure of the claimant or claimant’s representative to provide sufficient information to determine whether, or to what extent, benefits are covered as payable, the notice of extension shall specifically describe the required additional information needed, and the claimant or claimant’s representative shall be given at least 45 days from receipt of the notice within which to provide the specified information. Notification of the benefit determination following a request for additional information shall be made as soon as possible, but in no case later than 15 days after the earlier of (1) the licensee’s receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant’s representative to provide the specified additional information.
(d) The determination of a post service claim shall be made within 30 days of the date of filing. In the event the claimant fails to provide sufficient information to determine the claim, the carrier shall notify the claimant within 15 days as to what additional information is required to process the claim and the claimant shall be given at least 45 days to provide the required information. The 30-day period for claim determination shall be tolled until such time as the claimant submits the required information.
V. The manner and content of notification of claim benefit determinations shall be as follows:
(a) The licensee shall notify the claimant or claimant’s representative in writing or electronically of the claim determination.
(b) If the claim benefit determination is a claim denial, the notice shall include:
(1) The specific reason or reasons for the determination and shall refer to the specific provision of the policy or plan on which the determination is based.
(2) A statement of the claimant’s right or the right of the claimant’s representative to access the internal grievance process and the process for obtaining external review.
(3) If the claim denial is based upon a determination that the claim is experimental or investigational or not medically necessary or appropriate:
(A) The name and credentials of the carrier or other licensed entity, the medical director, including board status and the state or states where the person is currently licensed. If the person making the claim denial is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person; and
(B) An explanation of the clinical rationale for the determination. This explanation shall recite the terms of the plan or the policy or of any clinical review criteria or any internal rule, guideline, protocol, or other similar provision that was relied upon in making the claim denial and how these provisions apply to the claimant’s specific medical circumstances;
(4) If an internal rule, guideline, protocol, or other similar provision was relied upon in making the benefit determination, a statement that such rule, guideline, protocol, or other similar provision was relied upon in making the claim denial;
(5) If clinical review criteria were relied upon in making the benefit determination, a statement that such clinical review criteria were relied upon in making the claim denial. The recitation of terms of the clinical review criteria required under RSA 420-E:4, V(b)(3)(B) shall be accompanied by the following notice: “The clinical review criteria provided to you are used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract;”
(6) In the case of a denial of a benefit concerning a claim involving urgent care or in the case of a denial of a claim related to continuation of an ongoing course of treatment for a person who has received emergency services, but who has not been discharged from a facility, a description of the expedited review applicable to such a claim shall be included in the determination. For all other claim benefit determinations, a description of the grievance process shall be specifically described in the determination.
VI. A licensee shall file with the department a copy of the materials designed to inform patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan and an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed.
VII. In any request for a benefit determination, the claimant may authorize a representative to pursue the claim or benefit determination by submitting a written statement to the licensee that acknowledges the representation.
VIII. No fees or costs shall be assessed against a claimant related to a request for claim benefit determination.