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| Home > Statutes > Usa Arizona |
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USA Statutes : arizona
Title : Insurance
Chapter : UTILIZATION REVIEW
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20-2501 Definitions; scope
A. In this chapter, unless the context otherwise requires:
1. "Adverse decision" means a utilization review determination by the utilization
review agent that a requested service or claim for service is not a covered service or is
not medically necessary under the plan if that determination results in a documented
denial or nonpayment of the service or claim.
2. "Benefits based on the health status of the insured" means a contract of
insurance to pay a fixed benefit amount, without regard to the specific services
received, to a policyholder who meets certain eligibility criteria based on health status
including:
(a) A disability income insurance policy that pays a fixed daily, weekly or monthly
benefit amount to an insured who is deemed disabled as defined by the policy terms.
(b) A hospital indemnity policy that pays a fixed daily benefit during hospital
confinement.
(c) A disability insurance policy that pays a fixed daily, weekly or monthly
benefit amount to an insured who is certified by a licensed health care professional as
chronically ill as defined by the policy terms.
(d) A disability insurance policy that pays a fixed daily, weekly or monthly
benefit amount to an insured who suffers from a prolonged physical illness, disability or
cognitive disorder as defined by the policy terms.
3. "Claim" means a request for payment for a service already provided. Claim does
not include:
(a) Claim adjustments for usual and customary charges for a service or coordination
of benefits between health care insurers.
(b) A request for payment under a policy or contract that pays benefits based on
the health status of the insured and that does not reimburse the cost of or provide
covered services.
4. "Covered service" means a service that is included in a policy, evidence of
coverage or similar document that specifies which services, insurance or other benefits
are included or covered.
5. "Denial" means a direct or indirect determination regarding all or part of a
request for any service or a direct determination regarding a claim that may trigger a
request for review or reconsideration. Denial does not include:
(a) Enforcement of a health care insurer's deductibles, copayments or coinsurance
requirements or adjustments for usual and customary charges, deductibles, copayments or
coinsurance requirements for a service or coordination of benefits between health care
insurers.
(b) The rejection of a request for payment under a policy or contract that pays
benefits based on the health status of the insured and that does not reimburse the cost
of or provide covered services.
6. "Department" means the department of insurance.
7. "Director" means the director of the department of insurance.
8. "Health care insurer" means a disability insurer, group disability insurer,
blanket disability insurer, health care services organization, hospital service
corporation, prepaid dental plan organization, medical service corporation, dental
service corporation or optometric service corporation or a hospital, medical, dental and
optometric service corporation.
9. "Indirect denial" means a failure to communicate authorization or
nonauthorization to the member by the utilization review agent within ten business days
after the utilization review agent receives the request for a covered service.
10. "Provider" means the physician or other licensed practitioner identified to the
utilization review agent as having primary responsibility for providing care, treatment
and services rendered to a patient.
11. "Service" means a diagnostic or therapeutic medical or health care service,
benefit or treatment.
12. "Utilization review" means a system for reviewing the appropriate and efficient
allocation of inpatient hospital resources, inpatient medical services and outpatient
surgery services that are being given or are proposed to be given to a patient, and of
any medical, surgical and health care services or claims for services that may be covered
by a health care insurer depending on determinable contingencies, including without
limitation outpatient services, in-office consultations with medical specialists,
specialized diagnostic testing, mental health services, emergency care and inpatient and
outpatient hospital services. Utilization review does not include elective requests for
the clarification of coverage.
13. "Utilization review agent" means a person or entity that performs utilization
review. For purposes of article 2 of this chapter, utilization review agent has the same
meaning prescribed in section 20-2530. For purposes of this chapter, utilization review
agent does not include:
(a) A governmental agency.
(b) An agent that acts on behalf of the governmental agency.
(c) An employee of a utilization review agent.
14. "Utilization review plan" means a summary description of the utilization review
guidelines, protocols, procedures and written standards and criteria of a utilization
review agent.
B. For the purposes of this chapter, utilization review by an optometric service
corporation applies only to nonsurgical medical and health care services.
20-2502 Utilization review activities; exemptions
A. A utilization review agent shall not conduct utilization review in this state
unless the utilization review agent meets or is exempt from the provisions of this
article.
B. A person is exempt from the provisions of this article if the person:
1. Is accredited by the utilization review accreditation commission, the national
committee for quality assurance or any other nationally recognized accreditation process
recognized by the director.
2. Conducts internal utilization review for hospitals, home health agencies,
clinics, private offices or other health facilities or entities if the review does not
result in the approval or denial of payment for hospital or medical services.
3. Conducts utilization review activities exclusively for work related injuries and
illnesses covered under the workers' compensation laws in title 23.
4. Conducts utilization review activities exclusively for a self-funded or
self-insured employee benefit plan if the regulation of that plan is preempted by section
514(b) of the employee retirement income security act of 1974, 29 United States Code
section 1144(b).
C. A utilization review agent shall conduct utilization review in accordance with
the agent's utilization review plan that is on file with the department pursuant to
section 20-2505 and in accordance with section 20-2532.
20-2503 Utilization review standards; applicability; definition
A. The utilization review standards established in this chapter apply to
prospective, concurrent and retrospective utilization review for:
1. Inpatient admissions to hospitals and other inpatient facilities.
2. Outpatient admissions to surgical facilities.
3. Outpatient surgical services provided in a health care provider's office.
4. Medical, surgical and health care services that may be covered by a health care
insurer depending on determinable contingencies, including without limitation outpatient
services, in-office consultations with medical specialists, specialized diagnostic
testing, mental health services, emergency care and inpatient and outpatient hospital
services.
B. For purposes of this section "inpatient admissions" includes inpatient
admissions to all acute medical, surgical, obstetrical, psychiatric and chemical
dependency inpatient services at a licensed hospital or other inpatient facility.
20-2504 Utilization review agents; certification; rules
A. The director shall issue a certificate to a utilization review agent that meets
all of the requirements of this chapter and all applicable rules. A utilization review
agent shall submit a signed and notarized application on a form prescribed by the
director.
B. A certificate is not transferable.
C. The director may adopt rules consistent with the requirements of this chapter.
D. Except as provided in section 20-2532, information required by the department
with respect to customers, patients or utilization review plans is confidential and is
not open to public inspection.
E. The utilization review agent shall pay all certification expenses as provided in
section 20-2506.
20-2505 Application for certification
A utilization review agent applying for a certificate shall submit the following
information to the department:
1. A signed and notarized application on a form prescribed by the director.
2. A utilization review plan that includes a summary description of review
guidelines, protocols and procedures, standards and criteria to be used in evaluating
inpatient hospital care, inpatient medical care, outpatient surgical care and any
medical, surgical and health care services that may be covered by a health care insurer
and the provisions by which patients, providers or hospitals may seek reconsideration or
appeal of decisions made by the utilization review agent.
3. The professional qualifications of the personnel either employed or under
contract to perform the utilization review. Personnel conducting utilization review
shall have current licenses that are in good standing and without restrictions from a
state health care professional licensing agency in the United States and may be a member
of a profession that practices inpatient hospital or outpatient surgical care.
4. A description of the policies and procedures that ensure that a representative
of the utilization review agent is available to receive and send the notice and
acknowledgments prescribed in article 2 of this chapter and is reasonably accessible to
patients and providers in this state and the department by a toll free telephone line or
by acceptance of long-distance collect calls for forty hours each week during normal
business hours.
5. A description of the policies and procedures that ensure that the utilization
review agent will follow applicable state and federal laws to protect the confidentiality
of individual medical records.
6. A copy of the materials or a description of the procedure designed to inform
patients and providers, as appropriate, of the requirements of the utilization review
plan.
20-2506 Certification; responsibilities of department; cost recovery
A. The director shall examine the affairs, transactions, accounts and records of
each utilization review agent before issuing an initial certificate and as often as the
director deems it necessary in order to determine if a utilization review agent is in
compliance with this chapter. The department shall not make any determination of quality
of care, appropriateness of utilization review recommendations or medical necessity
relating to any plan of care or treatment.
B. All examination and examination related expenses shall be charged to the
utilization review agent and shall be paid by the director out of the insurance
examiners' revolving fund in accordance with section 20-159.
C. The director may use independent contract examiners pursuant to sections 20-148
and 20-149 to perform the examinations under this section.
D. Any expenses of examinations not paid by the utilization review agent within
thirty days of the billing of the examination expenses shall be paid by the health care
insurer that used the services or that contracted with the utilization review agent. If
more than one health care insurer used the services of or contracted with a utilization
review agent each health care insurer shall pay an equal share of the uncollected
expenses.
20-2507 Certificates; renewal
A. A certificate expires on the third anniversary of its effective date unless the
certificate is renewed for a three year term as provided in this section.
B. A certificate holder may renew an unexpired certificate for an additional three
year term if the certificate holder meets the requirements of this chapter.
20-2508 Denial, suspension or revocation of certificates; hearing; civil penalties
A. The director shall deny a certificate if the director finds that the utilization
review agent does not:
1. Have an allopathic or osteopathic physician available to supervise utilization
review activities of any medical, surgical or health care services except that:
(a) A dental service corporation that is licensed pursuant to chapter 4, article 3
of this title and a prepaid dental plan organization that is licensed pursuant to chapter
4, article 7 of this title may have a licensed dentist supervise or conduct utilization
review activities for health care services that involve dental care.
(b) An optometric service corporation that is licensed pursuant to chapter 4,
article 3 of this title may have a licensed optometrist supervise or conduct utilization
review activities for health care services that involve optometric care.
2. Meet all applicable department rules relating to the qualifications of
utilization review agents or the performance of utilization review.
3. Provide assurances satisfactory to the director that the procedure and policies
of the utilization review agent will protect the confidentiality of medical records and
the utilization review agent will be reasonably accessible to patients and providers in
this state and the department by a toll free telephone line or by acceptance of
long-distance collect calls for forty hours each week during normal business hours.
B. The director shall deny a certificate to a utilization review agent who has been
convicted of a misdemeanor involving moral turpitude or a felony or who employs a person
who has been convicted of a felony.
C. The director may suspend, revoke or refuse to renew a certificate issued under
this chapter if after giving notice to the utilization review agent, and holding a
hearing if demanded by the agent, the director finds that the agent has violated this
chapter or a rule adopted under this chapter.
D. If after a hearing the director finds that the agent has violated this chapter
or an applicable rule or order adopted under this chapter, the director shall issue an
order that specifies the violation and may impose a civil penalty of not more than two
hundred fifty dollars for each violation or an aggregate civil penalty of not more than
two thousand five hundred dollars. The director may also impose a civil penalty of not
more than two thousand five hundred dollars for each knowing violation or an aggregate
civil penalty of not more than fifteen thousand dollars. The director shall deposit,
pursuant to sections 35-146 and 35-147, all monies in the state general fund. A civil
penalty is in addition to any other applicable penalty or restraint provided in this
chapter and may be recovered in a civil action brought by the director.
E. A certificate does not expire or terminate until a pending department
investigation is resolved but is suspended on the date it would otherwise expire or
terminate. The utilization review agent shall not transact business in this state until
the investigation is completed.
F. When the director suspends or revokes a certificate the director shall
immediately notify the utilization review agent either by personal service or by mail
addressed to the agent at the agent's address of record. Notice by mail is effective at
the time it is mailed.
G. The utilization review agent shall deliver a revoked or suspended certificate to
the director on the director's request.
H. The director shall not issue a new certificate earlier than one year after the
date of a previous revocation. Agents shall reapply to the director and shall meet all
the requirements of this chapter to obtain a new certificate.
I. If the certificate of a firm or corporation is suspended or revoked, no member
of that firm or officer or director of the corporation may hold a certificate during the
period of the suspension or revocation unless the director determines, based on
substantial evidence, that the member, officer or corporation director was not personally
at fault.
20-2509 Confidentiality
A. A utilization review agent shall file with the director written procedures for
assuring that patient information it obtains during the process of utilization review is
maintained as confidential in accordance with applicable federal and state laws, is used
solely for the purposes of utilization review, quality assurance, discharge planning and
catastrophic case management and is shared only with agencies authorized by the patient
in writing and on a form prescribed by the director to receive the information. Summary
data are not confidential if the data do not provide sufficient information to allow
identification of individual patients. This subsection does not permit a person to
obtain information without complying with other requirements of this title.
B. A utilization review agent shall comply with all applicable state and federal
laws relating to the confidentiality of medical records.
20-2510 Health care insurers requirements; medical directors
A. A health care insurer that proposes to provide coverage of inpatient hospital
and medical benefits, outpatient surgical benefits or any medical, surgical or health
care service for residents of this state with utilization review of those benefits shall
meet at least one of the following requirements:
1. Have a certificate issued pursuant to this chapter.
2. Be accredited by the utilization review accreditation commission, the national
committee for quality assurance or any other nationally recognized accreditation process
recognized by the director.
3. Contract with a utilization review agent that has a certificate issued pursuant
to this chapter.
4. Contract with a utilization review agent that is accredited by the utilization
review accreditation commission, the national committee for quality assurance or any
other nationally recognized accreditation process recognized by the director.
5. Provide to the director a signed and notarized statement that the health care
insurer has submitted an application for accreditation to the utilization review
accreditation commission or the national committee for quality assurance and is awaiting
completion of the accreditation review process. On completion of the accreditation
review process, the insurer shall provide to the director adequate proof that the insurer
has been accredited. If the insurer is denied accreditation, within sixty days after the
denial the insurer shall meet at least one of the requirements set forth in paragraph 1,
2, 3 or 4 of this subsection.
B. Except as provided in subsections C and D of this section, any direct denial of
prior authorization of a service requested by a health care provider on the basis of
medical necessity by a health care insurer shall be made in writing by a medical director
who holds an active unrestricted license to practice medicine in this state pursuant to
title 32, chapter 13 or 17. The written denial shall include an explanation of why the
treatment was denied, and the medical director who made the denial shall sign the written
denial. The health care insurer shall send a copy of the written denial to the health
care provider who requested the treatment. Health care insurers shall maintain copies of
all written denials and shall make the copies available to the department for inspection
during regular business hours. The medical director is responsible for all direct denials
that are made on the basis of medical necessity. Nothing in this section prohibits a
health care insurer from consulting with a licensed physician whose scope of practice may
provide the health care insurer with a more thorough review of the medical necessity.
C. For determinations made pursuant to subsection B of this section, a dental
service corporation as defined in section 20-822 or a prepaid dental plan organization as
defined in section 20-1001 may use as a medical director either:
1. An individual who holds an active unrestricted license to practice dentistry in
this state pursuant to title 32, chapter 11.
2. A physician who holds an active unrestricted license to practice medicine in
this state pursuant to title 32, chapter 13 or 17.
D. For determinations made pursuant to subsection B of this section, an optometric
service corporation may use as a medical director either:
1. An individual who holds an active unrestricted license to practice optometry in
this state pursuant to title 32, chapter 16.
2. A physician who holds an active unrestricted license to practice medicine in
this state pursuant to title 32, chapter 13 or 17.
20-2511 Violation; injunctive relief
If the director believes that a utilization review agent is violating or is about to
violate section 20-2502, the director may order the agent to cease and desist. The
director through the attorney general may file a complaint in the superior court in the
county in which the agent transacts utilization review business to enjoin and restrain
the agent from committing or continuing the violation. If the director orders the
utilization review agent to cease and desist, the agent may request a hearing pursuant to
title 41, chapter 6, article 10 and, except as provided in section 41-1092.08, subsection
H, seek judicial review pursuant to title 12, chapter 7, article 6. If the director files
a complaint through the attorney general the superior court has jurisdiction of the
proceeding and may make and enter an order or judgment awarding preliminary or final
relief as in its judgment is proper. 20-2530 Definitions
For the purposes of this article:
1. "Member" means a person who is covered under a health care plan provided by a
health care insurer or that person's treating provider, parent, legal guardian, surrogate
who is authorized to make health care decisions for that person by a power of attorney, a
court order or the provisions of section 36-3231, or agent who is an adult and who has
the authority to make health care treatment decisions for that person pursuant to a
health care power of attorney.
2. "Utilization review agent" means those persons and entities that perform
utilization review as defined in section 20-2501 and includes any health care insurer
whose utilization review plan includes the direct or indirect denial of requested medical
or health care services or the denial of claims.
20-2531 Applicability; requirements
A. Notwithstanding article 1 of this chapter and subject to subsection B of this
section, this article applies to all utilization review decisions made by utilization
review agents and health care insurers operating in this state.
B. Each utilization review agent and each health care insurer operating in this
state whose utilization review system includes the power to affect the direct or
indirect denial of requested medical or health care services or claims for medical or
health care services shall adopt written utilization review standards and criteria and
processes for the review, reconsideration and appeal of denials that do all of the
following:
1. Meet the requirements of this article.
2. Are consistent with chapter 1 of this title.
3. Comply with section 20-2505, paragraphs 2 through 6.
C. This article does not apply to utilization review:
1. Performed under contract with the federal government for utilization review of
patients eligible for all services under title XVIII of the social security act.
2. Performed by a self-insured or self-funded employee benefit plan or a
multiemployer employee benefit plan created in accordance with and pursuant to 29
United States Code section 186(c) if the regulation of that plan is preempted by
section 514(b) of the employee retirement income security act of 1974 (29 United States
Code section 1144(b)), but this article does apply to a health care insurer that
provides coverage for services as part of an employee benefit plan.
3. Of work related injuries and illnesses covered under the workers' compensation
laws in title 23.
4. Performed under the terms of a policy that pays benefits based on the health
status of the insured and does not reimburse the cost of or provide covered services.
5. Performed under the terms of a long-term care insurance policy as defined in
section 20-1691.
6. Performed under the terms of a medicare supplement policy as defined by the
department.
D. This article does not create any new private right or cause of action for or
on behalf of any member. This article provides only an administrative process for a
member to pursue an external independent review of a denial for a covered service or
claim for a covered service.
E. Utilization review activities involving retrospective claims review shall be
limited to the provisions of this article only as clearly and specifically provided in
the provisions of this article.
20-2532 Utilization review standards and criteria; requirements
A. Each utilization review agent shall:
1. Adopt a written utilization review plan with standards and criteria that apply
to all utilization review decisions and that are objective, clinically valid and
compatible with established principles of health care.
2. Establish the utilization review plan with input from physician advisors who
represent major medical specialties and who are certified or board eligible under the
standards of the appropriate American medical specialty board.
3. Include in the adopted utilization review plan a process for prompt initial
reconsideration of an adverse decision and a process for appeals that meet the
requirements of this article. This paragraph shall not apply to utilization review
activities limited to retrospective claims review.
B. Deviations from the written standards and criteria in the utilization review
plan are permitted if the utilization review agent determines that the member and other
members with similar symptoms and diagnoses would materially benefit from new treatments
available because of medical or technological advances made since the adoption of the
utilization review plan and made in accordance with accepted medical standards. This
subsection shall not apply to utilization review activities limited to retrospective
claims review. Nothing in this subsection creates a private right or cause of action
against a health care insurer or utilization review agent for failure to deviate from the
utilization review plan.
C. A health care insurer who utilizes the services of an outside utilization review
agent shall adopt a utilization review plan pursuant to subsections A and B of this
section. The utilization review plan adopted and filed by the health care insurer who
utilizes the services of an outside utilization review agent is deemed adopted by that
utilization review agent.
D. A health care insurer who utilizes the services of an outside utilization review
agent is responsible for the utilization review agent's acts that are within the scope of
the written and filed utilization review plan.
E. Notwithstanding section 20-2502, subsection B, each utilization review agent
shall file a notice with the director that provides a specific description and the
published date of the source of the written standards and criteria of the utilization
review plan and that certifies that the utilization review plan in use complies with the
requirements of this section, is available for review and inspection at a designated
location in this state or at an office accessible to authorized representatives of the
director in another state and is the complete utilization review plan with all standards
and criteria on which utilization review decisions are based. A copy of any portion of
the utilization review plan on which any adverse decisions have been based shall be made
before the effective date of any modification and the utilization review agent shall
retain a copy at the designated location for review and inspection for a period of five
years after the date of the modification. If at any time a complete change in the
written standards and criteria occurs, the utilization review agent shall submit a new
certification filing notice with the director.
F. On or before March 1 of each year after the year in which the utilization review
agent filed the notice prescribed in subsection E of this section, the utilization review
agent or the agent's successor shall submit a signed and notarized annual report to the
director that includes the designated location for review and inspection by the director
or the director's authorized representative and that certifies that:
1. The utilization review plan and all modifications remain in compliance with the
requirements of this section.
2. The utilization review agent will conduct all utilization reviews in accordance
with the plan.
3. All adverse decisions made in the prior year were based on the plan in effect on
the date of those decisions.
G. On written request, the utilization review agent shall provide copies to any
member or the member's treating provider of:
1. Those portions of the utilization review agent's utilization review plan that
are relevant to the request for a covered service or claim for a covered service.
2. The protocols or guidelines that were used if the standards and criteria adopted
are based on protocols or guidelines developed by an American medical specialty board.
H. Any person who requests records pursuant to subsection G of this section shall
direct the request to the utilization review agent and not to the department.
I. If the utilization review plan is copyrighted by a person other than the
utilization review agent, the health care insurer shall make a good faith effort to
obtain permission from that person to make copies of the relevant material. If the
health care insurer is unable to secure copyright permission, the utilization review
agent shall provide a detailed summary of the relevant portions of the utilization review
plan.
J. Health care insurers having utilization review activities limited to
retrospective claims review shall be required to adopt only those procedures and sources
of review that are traditionally associated with and necessary for retrospective claims
review.
20-2533 Denial; levels of review; disclosure; additional time after service by mail; review process
A. Any member who is denied a covered service or whose claim for a service is
denied may pursue the applicable review process prescribed in this article. Except as
provided in sections 20-2534 and 20-2535, health care insurers shall provide at least the
following levels of review, as applicable:
1. An expedited medical review and expedited appeal pursuant to section 20-2534.
2. An informal reconsideration pursuant to section 20-2535.
3. A formal appeal process pursuant to section 20-2536.
4. An external independent review pursuant to section 20-2537.
B. A health care insurer may offer additional levels of review other than the
levels prescribed in subsection A of this section as long as the additional levels of
review do not increase the time period limitations prescribed by this article.
C. At the time coverage is initiated, each health care insurer that operates in
this state and whose utilization review system includes the power to affect the direct or
indirect denial of requested medical or health care services or claims for medical or
health care services shall include a separate information packet that is approved by the
director with the member's policy, evidence of coverage or similar document. At the time
coverage is renewed, each health care insurer shall include a separate statement with the
member's policy, evidence of coverage or similar document that informs the member that
the member can obtain a replacement packet that explains the appeal process by contacting
a specific department and telephone number. A health care insurer shall also provide a
copy of the information packet to the member or the member's treating provider on request
and to the member within five business days after the date the appeal is initiated
pursuant to section 20-2534, 20-2535 or 20-2536. The information packet provided by the
health care insurer shall include all of the following information:
1. A detailed description and explanation of each level of review prescribed in
subsection A of this section and notice of the member's right to proceed to the next
level of review if the prior review is unsuccessful.
2. An explanation of the procedures that the member must follow, including the
applicable time periods, for each level of review prescribed in subsection A of this
section and an explanation of how the member may obtain the member's medical records
pursuant to title 12, chapter 13, article 7.1.
3. The specific title and department of the person and the address, telephone
number and telefacsimile number of that person whom the member must notify at each level
of review prescribed in subsection A of this section in order to pursue that level of
review.
4. The specific title and department of the person and the address, telephone
number and telefacsimile number of the person who will be responsible for processing that
review.
5. A notice that if the member decides to pursue an appeal the member must provide
the person who will be responsible for processing the appeal with any material
justification or documentation for the appeal at the time that the member files the
written appeal.
6. A description of the utilization review agent's and health care insurer's roles
at each level of review prescribed by subsection A of this section and an outline of the
director's role during the external independent review process, if not already described
in response to paragraph 1 of this subsection.
7. A notice that if the member participates in the process of review pursuant to
this article the member waives any privilege of confidentiality of the member's medical
records regarding any person who examined or will examine the member's medical records in
connection with that review process for the medical condition under review.
8. A statement that the member is not responsible for the costs of any external
independent review.
9. Standardized forms that are prescribed by the department and that a member may
use to file and pursue an appeal.
10. The name and telephone number for the department of insurance consumer
assistance office with a statement that the department of insurance consumer assistance
office can assist consumers with questions about the health care appeals process.
D. At the time of issuing a denial, the health care insurer shall notify the member
of the right to appeal under this article. A health care insurer that issues an
explanation of benefits document shall satisfy this obligation by prominently displaying
in the document a statement about the right to appeal. A health care insurer that does
not issue an explanation of benefits document shall satisfy this obligation through some
other reasonable means to assure that the member is apprised of the right to appeal at
the time of a denial. A reasonable means that includes giving the member's treating
provider a form statement about the right to appeal shall require the treating provider
to notify the member of the member's right to appeal.
E. Any written notice, acknowledgment, request, decision or other written document
required to be mailed pursuant to this article is deemed received by the person to whom
the document is properly addressed on the fifth business day after the request is mailed.
For the purposes of this subsection "properly addressed" means the last known address.
F. The director shall require any member who files a complaint with the department
relating to an adverse decision to pursue the review process prescribed in this article.
This subsection does not limit the director's authority pursuant to chapter 1, article 2
of this title.
G. If the member's complaint is an issue of medical necessity under the coverage
document and not whether the claim or service is covered, the informal reconsideration
shall be performed as prescribed by section 20-2535 by a licensed health care
professional. If the member's complaint is an issue of medical necessity under the
coverage document and not whether the claim or service is covered, the expedited review
or formal appeal shall be decided by a physician, provider or other health care
professional as prescribed by section 20-2534 or 20-2536. Any external independent review
shall be decided by a physician, provider or other health care professional as prescribed
by section 20-2537.
H. Any person given access to a member's medical records or other medical
information in connection with proceedings pursuant to this article shall maintain the
confidentiality of the records or information in accordance with title 12, chapter 13,
article 7.1.
20-2534 Expedited medical review; expedited appeal
A. Any member who is denied a request for a covered service may pursue an expedited
medical review of that denial if the member's treating provider certifies in writing and
provides supporting documentation to the utilization review agent that the time period
for the informal reconsideration process and formal appeal process prescribed in sections
20-2535 and 20-2536 is likely to cause a significant negative change in the member's
medical condition at issue that is subject to the appeal. The treating provider's
certification is not challengeable by the health care insurer. A health care insurer
whose utilization review activities consist only of claims review for services already
provided is not required to provide its members an expedited medical review or expedited
appeal pursuant to this section. A health care insurer who conducts utilization review of
claims in connection with services already provided is not required to provide its
members an expedited medical review or expedited appeal of a claim related to a service
already provided.
B. On receipt of the certification and supporting documentation, the utilization
review agent has one business day to make a decision and mail to the member and the
member's treating provider a notice of that decision, including the criteria used and the
clinical reasons for that decision and any references to supporting documentation. If the
member's complaint is an issue of medical necessity under the coverage document and not
whether the service is covered, before making a decision, the agent shall consult with a
physician or other health care professional who is licensed pursuant to title 32, chapter
7, 8, 11, 13, 14, 17, 19 or 29 or an out of state provider, physician or other health
care professional who is licensed in another state and who is not licensed in this state
and who typically manages the medical condition under review.
C. If the utilization review agent affirms the denial of the requested service, the
agent shall telephonically provide and mail to the member and the member's treating
provider a notice of the adverse decision and of the member's option to immediately
proceed to an expedited appeal pursuant to subsection E of this section.
D. At any time during the expedited appeal process, the utilization review agent
may request an expedited external independent review process pursuant to section 20-2537.
If the utilization review agent initiates the expedited external independent review
process, the utilization review agent does not have to comply with subsection E of this
section.
E. If the member chooses to proceed with an expedited appeal, the member's treating
provider shall immediately submit a written appeal of the denial of the service to the
utilization review agent and provide the utilization review agent with any additional
material justification or documentation to support the member's request for the service.
Within three business days after receiving the request for an expedited appeal, the
utilization review agent shall provide notice of the expedited appeal decision as
prescribed in this subsection. If the member's complaint is an issue of medical necessity
under the coverage document and not whether the service is covered, any provider,
physician or other health care professional who is licensed pursuant to title 32, chapter
7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an out of state provider, physician or other
health care professional who is licensed in another state and who is not licensed in this
state, who is employed or under contract with the utilization review agent and who is
qualified in a similar scope of practice as a provider, physician or other health care
professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19,
19.1 or 29 or an out of state provider, physician or other health care professional who
is licensed in another state and who is not licensed in this state and who typically
manages the medical condition under appeal shall review the expedited appeal and render a
decision based on the utilization review plan adopted by the utilization review agent.
Pursuant to the requirements of this subsection, the utilization review agent shall
select the provider, physician or other health care professional who shall review the
appeal and render the decision. If the utilization review agent, provider, physician or
other health care professional denies the expedited appeal, the utilization review agent
shall telephonically provide and mail to the member and the member's treating provider a
notice of the denial and of the member's option to immediately proceed to the external
independent review prescribed in section 20-2537.
F. If the utilization review agent, provider, physician or other health care
professional concludes that the covered service should be provided, the health care
insurer is bound by the utilization review agent's decision.
20-2535 Informal reconsideration
A. Any member who is denied a service and who does not qualify for an expedited
medical review pursuant to section 20-2534 may request, either orally or in writing, an
informal reconsideration of that denial by notifying the person described in section
20-2533, subsection C, paragraph 3. After the denial, the member has up to two years to
request an informal reconsideration. A health care insurer whose utilization review
consists only of claims review for services already provided is not required to provide
its members an informal reconsideration pursuant to this section. A health care insurer
who conducts utilization review of claims in connection with services already provided is
not required to provide its members an informal reconsideration of a claim related to a
service already provided.
B. The utilization review agent shall mail a written acknowledgment to the member
and the member's treating provider within five business days after the utilization review
agent receives the request for informal reconsideration.
C. The utilization review agent may request any pertinent medical records pursuant
to title 12, chapter 13, article 7.1 that are necessary for the informal reconsideration.
D. The utilization review agent has up to thirty days after receipt of the request
for reconsideration to mail to the member and the member's treating provider a notice of
the utilization review agent's decision and the criteria used and the clinical reasons
for that decision.
E. At any time during the informal reconsideration process, the utilization review
agent may submit a request to the director to initiate an external independent review
process pursuant to section 20-2537. At the same time that the utilization review agent
submits the request to the director, the utilization review agent shall also render a
written decision and shall send the written decision, including the criteria used and the
clinical reasons for that decision and any references to supporting documentation, to the
member, the member's treating provider and the director.
F. If the utilization review agent does not submit a request to the director
pursuant to subsection E of this section and at the conclusion of the informal
reconsideration process the utilization review agent denies the covered service or the
claim for the covered service, the utilization review agent shall provide the member and
the treating provider with a written statement of the agent's decision and the criteria
used and the clinical reasons for that decision, including any references to any
supporting documentation and a notice of the option to proceed after the formal appeal
process to an external independent review.
G. If the utilization review agent concludes that the covered service should be
provided or the claim for a covered service should be paid, the health care insurer is
bound by the utilization review agent's decision.
20-2536 Formal appeal
A. After any applicable informal reconsideration pursuant to section 20-2535, if
the utilization review agent denies the member's request for a covered service, the
member may appeal that adverse decision. The member shall mail a written appeal to the
utilization review agent within sixty days after receipt of the adverse decision. In the
event of a denial of a claim for a service that has already been provided, the member may
appeal that denial by filing a written appeal with the utilization review agent within
two years after receipt of the notice of the denial.
B. The utilization review agent shall mail a written acknowledgment to the member
and the member's treating provider within five business days after the agent receives the
formal appeal.
C. The member or the member's treating provider shall submit to the utilization
review agent with the written formal appeal any material justification or documentation
to support the member's request for the service or claim for a service.
D. If the member's complaint is an issue of medical necessity under the coverage
document and not whether the service is covered, a provider, physician or other health
care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17,
19, 19.1 or 29 or an out of state provider physician or other health care professional
who is licensed in another state and who is not licensed in this state, who is employed
or under contract with the utilization review agent and who is qualified in a similar
scope of practice as a provider, physician or other health care professional licensed
pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an out of state
provider, physician or other health care professional who is licensed in another state
and who is not licensed in this state and who typically manages the medical condition
under appeal shall review the appeal and render a decision based on the utilization
review plan adopted by the utilization review agent. Pursuant to the requirements of this
subsection, the utilization review agent shall select the provider, physician or other
health care professional who shall review the appeal and render the decision.
E. Except as provided in subsection F of this section, the utilization review agent
has:
1. With respect to adverse decisions relating to services that have not been
provided, up to thirty days after receipt of the written appeal to notify the member in
writing of the utilization review agent's decision and the criteria used and the clinical
reasons for that decision.
2. With respect to denials relating to claims that have already been provided, up
to sixty days after receipt of the written appeal to notify the member in writing of the
utilization review agent's decision and the criteria used and the clinical reasons for
that decision.
F. At any time during the formal appeal process, the utilization review agent may
request an external independent review process pursuant to section 20-2537. If the
utilization review agent initiates the external independent review process, the
utilization review agent does not have to comply with subsection E of this section.
G. If at the conclusion of the formal appeal process the utilization review agent
denies the appeal and the utilization review agent does not initiate the external
independent review process, the utilization review agent shall provide the member with
notice of the option to proceed to an external independent review pursuant to section
20-2537.
H. If the utilization review agent concludes that the covered service should be
provided or the claim for a covered service should be paid, the health care insurer is
bound by the utilization review agent's decision.
20-2537 External independent review; expedited external independent review
A. If the utilization review agent denies the member's request for a covered
service or claim for a covered service at both the informal reconsideration level and the
formal appeal level, or at the expedited medical review level, the member may initiate an
external independent review.
B. Except as provided in subsection K of this section, within thirty days after the
member receives written notice by the utilization review agent of the adverse decision
made pursuant to section 20-2534 or 20-2536, if the member decides to initiate an
external independent review, the member shall mail to the utilization review agent a
written request for an external independent review, including any material justification
or documentation to support the member's request for the covered service or claim for a
covered service.
C. Except as provided in subsection K of this section, within five business days
after the utilization review agent receives a request for an external independent review
from the member pursuant to subsection B of this section or the director pursuant to
subsection G of this section, or if the utilization review agent initiates an external
independent review pursuant to section 20-2536, subsection F, the utilization review
agent shall:
1. Mail a written acknowledgment to the director, the member, the member's treating
provider and the health care insurer.
2. Forward to the director the request for review, the terms of agreement in the
member's policy, evidence of coverage or a similar document and all medical records and
supporting documentation used to render the decision pertaining to the member's case, a
summary description of the applicable issues including a statement of the utilization
review agent's decision, the criteria used and the clinical reasons for that decision,
the relevant portions of the utilization review agent's utilization review plan and the
name and credentials of the licensed health care provider who reviewed the case as
required by section 20-2533, subsection G.
D. Except as provided in subsection K of this section, within five days after the
director receives all of the information prescribed in subsection C, paragraph 2 of this
section and if the case involves an issue of medical necessity under the coverage
document, the director shall choose an independent review organization procured pursuant
to section 20-2538 and forward to the organization all of the information required by
subsection C, paragraph 2 of this section.
E. Except as provided in subsection K of this section, for cases involving an issue
of medical necessity under the coverage document, within twenty-one days after the date
of receiving a case for independent review from the director, the independent review
organization shall evaluate and analyze the case and, based on all information required
under subsection C, paragraph 2 of this section, render a decision that is consistent
with the utilization review plan on whether or not the service or claim for the service
is medically necessary and send the decision to the director. Within five business days
after receiving a notice of decision from the independent review organization, the
director shall mail a notice of the decision to the utilization review agent, the health
care insurer, the member and the member's treating provider. The decision by the
independent review organization is a final administrative decision pursuant to title 41,
chapter 6, article 10 and is subject to judicial review pursuant to title 12, chapter 7,
article 6. The health care insurer shall provide any service or pay any claim determined
to be covered and medically necessary by the independent review organization for the case
under review regardless of whether judicial review is sought.
F. Except as provided in subsection K of this section, for cases involving an issue
of coverage, within fifteen business days after receipt of all of the information
prescribed in subsection C, paragraph 2 of this section from the utilization review
agent, the director shall determine if the service or claim is or is not covered and if
the adverse decision made pursuant to section 20-2536 conforms to the utilization review
agent's utilization review plan and this article and shall mail a notice of determination
to the utilization review agent, the health care insurer, the member and the member's
treating provider.
G. If the director finds that the case involves a medical issue or is unable to
determine issues of coverage, the director shall submit the member's case to the external
independent review organization in accordance with subsections E and K of this section.
H. After a decision is made pursuant to subsection E, F, G or K of this section,
the reconsideration, appeal and administrative processes are completed and the
department's role is ended, except:
1. To transmit, when necessary, a record of the proceedings to superior court or to
the office of administrative hearings.
2. To issue a final administrative decision pursuant to section 41-1092.08.
I. Except as provided in subsection K of this section, on written request by the
independent review organization, the member or the utilization review agent, the director
may extend the twenty-one day time period prescribed in subsection E of this section for
up to an additional thirty days if the requesting party demonstrates good cause for an
extension.
J. A decision made by the director or an independent review organization pursuant
to this section is admissible in proceedings involving a health care insurer or
utilization review agent.
K. If the utilization review agent denies the member's request for a covered
service or claim for a covered service at the expedited medical review level presented
and resolved pursuant to section 20-2534, subsections A and E, the member may initiate an
expedited external independent review in accordance with the following:
1. Within five business days after the member receives written notice by the
utilization review agent of the adverse decision made pursuant to section 20-2534, if the
member decides to initiate an external independent review, the member shall mail to the
utilization review agent a written request for an expedited external independent review,
including any material justification or documentation to support the member's request for
the covered service or claim for a covered service.
2. Within one business day after the utilization review agent receives a request
for an external independent review from the member pursuant to this subsection or if the
utilization review agent initiates an external independent review pursuant to section
20-2534, subsection D, the utilization review agent shall:
(a) Mail a written acknowledgment to the director, the member, the member's
treating provider and the health care insurer.
(b) Forward to the director the request for an expedited independent external
review, the terms of agreement in the member's policy, evidence of coverage or a similar
document and all medical records and supporting documentation used to render the decision
pertaining to the member's case, a summary description of the applicable issues including
a statement of the utilization review agent's decision, the criteria used and the
clinical reasons for that decision, the relevant portions of the utilization review
agent's utilization review plan and the name and credentials of the licensed health care
provider who reviewed the case as required by section 20-2534, subsection B.
3. Within two business days after the director receives all of the information
prescribed in this subsection and if the case involves an issue of medical necessity, the
director shall choose an independent review organization procured pursuant to section
20-2538 and forward to the organization all of the information required by this
subsection.
4. For cases involving an issue of medical necessity, within five business days
from the date of receiving a case for expedited external independent review from the
director, the independent review organization shall evaluate and analyze the case and,
based on all information required under subsection C, paragraph 2 of this section, render
a decision that is consistent with the utilization review plan on whether or not the
service or claim for the service is medically necessary and send the decision to the
director. Within one business day after receiving a notice of decision from the
independent review organization, the director shall mail a notice of the decision to the
utilization review agent, the health care insurer, the member and the member's treating
provider. The decision by the independent review organization is a final administrative
decision pursuant to title 41, chapter 6, article 10 and, except as provided in section
41-1092.08, subsection H, is subject to judicial review pursuant to title 12, chapter 7,
article 6. The health care insurer shall provide any service or pay any claim determined
to be covered and medically necessary by the independent review organization for the case
under review regardless of whether judicial review is sought.
5. For cases involving an issue of coverage, within two business days after receipt
of all of the information prescribed in subsection C of this section from the utilization
review agent, the director shall determine if the service or claim is or is not covered
and if the adverse decision made pursuant to section 20-2534 conforms to the utilization
review agent's utilization review plan and this article and shall mail a notice of
determination to the utilization review agent, the health care insurer, the member and
the member's treating provider.
L. Notwithstanding title 41, chapter 6, article 10 and section 12-908, if a party
to a decision issued under this section seeks further administrative review, the
department shall not be a party to the action unless the department files a motion to
intervene in the action.
M. The independent review organization, the director or the office of
administrative hearings may not order the health care insurer to provide a service or to
pay a claim for a benefit or service that is excluded from coverage by the contract.
N. The health care insurer shall provide any service or pay any claim determined in
a final administrative decision to be covered and medically necessary for the case under
review regardless of whether judicial review is sought. Any proceedings before the office
of administrative proceedings that involve an expedited external independent review and
that are subject to subsection K of this section shall be promptly instituted and
completed.
20-2538 Independent review organizations
A. Pursuant to title 41, chapter 23, the director shall procure as many independent
review organizations as necessary and practicable to perform the independent medical
reviews described in section 20-2537.
B. Through the procurement process the director shall ensure that any procured
independent review organization uses physicians or other health care professionals who
are licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 17, 19, 19.1 or 29 or out of
state physicians or other health care professionals who are licensed in another state and
who are not licensed in this state, who are board certified or board eligible by the
appropriate American medical specialty board and who are in the same or a similar scope
of practice as a physician or another health care professional who is licensed pursuant
to title 32, chapter 7, 8, 11, 13, 14, 17, 19, 19.1 or 29 or an out of state physician or
another health care professional who is licensed in another state and who is not licensed
in this state and who typically manages the medical condition, procedure or treatment
under review.
C. The independent review organization and its individual reviewer shall not have a
substantial interest in the member, provider or health care insurer involved in the
particular case under review or any other conflict of interest that will preclude the
reviewer from making a fair and impartial decision. The individual reviewer shall not be
a policyholder or insured member of a company whose case is being reviewed.
D. An out of state physician or another health care professional who is licensed in
another state and who is not licensed in this state in a field substantially similar to
the laws of this state applicable to physicians or other health care professionals who
are licensed under title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 and who are
certified or board eligible by the appropriate American medical specialty board may serve
as an independent reviewer for the procured independent review organization and that
provider's analysis, assessment or decision for the independent review organization does
not constitute the practice of medicine or any other health care profession in this
state.
E. The director, any procured independent review organization or any independent
reviewer acting in good faith is not liable for the analysis, assessment or decision of
any case reviewed pursuant to this article.
20-2539 Rules
The director may adopt rules pursuant to title 41, chapter 6 to carry out this
article.
20-2540 Health care appeals fund
A. The health care appeals fund is established consisting of monies collected
pursuant to subsection B of this section. The fund is a special state fund pursuant to
section 35-142, subsection A, paragraph 8. Monies in the fund do not revert to the state
general fund. The department shall administer the fund. Monies in the fund are
continuously appropriated and are exempt from the provisions of section 35-190 relating
to lapsing of appropriations.
B. The director shall charge an appealing member's health care insurer for all
amounts owed to the independent review organization, pursuant to subsection C of this
section, to decide the member's appeal. The director may assess each health care insurer
for administrative costs for implementing and maintaining the external independent review
process as prescribed in this section and section 20-2538. The director shall deposit all
collected monies in the fund.
C. The director shall use monies in the fund to:
1. Compensate procured independent review organizations for performing independent
medical reviews on a per case rate unless the director determines that another method is
necessary to carry out the purposes of this article.
2. Perform the responsibilities relating to the procurement of independent review
organizations and to implement and maintain the external independent review process.
D. An independent review organization shall submit to the director for approval a
detailed invoice consistent with the method of payment prescribed in subsection C of this
section.
20-2541 Health care insurer fee
The director of the department of insurance may assess each health care insurer that
is authorized to transact insurance:
1. A single fee of not more than two hundred dollars per insurer.
2. Up to two hundred dollars each year for the costs of performing the
responsibilities relating to the procurement of independent review organizations as
prescribed in sections 20-2537 and 20-2538 and for implementing and maintaining the
external independent review process, including processing and paying claims through the
health care appeals fund established by section 20-2540. The department of insurance is
authorized one full-time equivalent position to perform these responsibilities.
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