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USA Statutes : maine
Title : Title 24-A. MAINE INSURANCE CODE
Chapter : Chapter 34. LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES (HEADING. PL 1989, c. 556, Pt. C, @2 (new))
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Title 24-A - §2771. Review entities
Title 24-A: MAINE INSURANCE CODE
Chapter 34: LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES (HEADING: PL 1989, c. 556, Pt. C, @2 (new))
§2771. Review entities
1. Licensure. A person, partnership or corporation, other than an insurer, nonprofit service organization, health maintenance organization,
preferred provider organization or employee of those exempt organizations, that performs medical utilization review services
on behalf of commercial insurers, nonprofit service organizations, 3rd-party administrators, health maintenance organizations,
preferred provider organizations or employers shall apply for licensure by the Bureau of Insurance and pay an application
fee of not more than $400 and an annual license fee of not more than $100; except that programs of review of medical services
for occupational claims compensated under Title 39-A are subject only to the certification requirements of that title and
are not subject to licensure under this section. A person, partnership or corporation, other than an insurer or nonprofit
service organization, health maintenance organization, preferred provider organization or the employees of exempt organizations,
may not perform utilization review services or medical utilization review services unless the person, partnership or corporation
has received a license to perform those activities.
[1995, c. 332, Pt. M, §5 (amd).]
2. Listing. The Bureau of Insurance shall compile and maintain a current listing of persons, partnerships or corporations licensed pursuant
to this section.
[1989, c. 556, Pt. C, §2 (new).]
3. Information required. Each person, partnership or corporation licensed pursuant to this section shall, at the time of initial licensure and on
or before April 1st of each succeeding year, provide the Bureau of Insurance with the following information:
A. The process by which the entity carries out its utilization review services. The information provided to the bureau must
include the categories of health care personnel that perform any activities coming under the definition of utilization review
and whether or not these individuals are licensed in the State. The information provided to the bureau also must include
copies of any licensure agreements the utilization review entity has in effect with any entity that sells or furnishes the
utilization review entity with medical utilization review criteria and the expiration date of any such agreements. If the
utilization review entity develops its own medical utilization review criteria, the utilization review entity shall include
copies of any policies and procedures or both for the use of the criteria;
[1995, c. 332, Pt. M, §6 (amd).]
B. The process used by the entity for addressing beneficiary or provider complaints;
[1989, c. 556, Pt. C, §2 (new).]
C. The types of utilization review programs offered by the entity, such as:
(1) Second opinion programs;
(2) Prehospital admission certification;
(3) Preinpatient service eligibility determination; or
(4) Concurrent hospital review to determine appropriate length of stay; and
[1989, c. 556, Pt. C, §2 (new).]
D. The process chosen by the entity to preserve beneficiary confidentiality of medical information.
[1989, c. 556, Pt. C, §2 (new).]
As part of its initial application, the entity shall submit copies of all materials to be used to inform beneficiaries and
providers of the requirements of its utilization review plans and their rights and responsibilities under the plan.
[1995, c. 332, Pt. M, §6 (amd).]
4. Transition for existing entities. Notwithstanding subsection 1, persons, partnerships or corporations performing utilization review services on the effective
date of this section shall have 90 days from its effective date to submit an application to the superintendent. The superintendent
shall act upon those applications within 6 months of the date of receipt of the application, during which time the review
entities may continue to perform medical utilization review services.
[1989, c. 556, Pt. C, §2 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2772. Minimum standards
Title 24-A: MAINE INSURANCE CODE
Chapter 34: LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES (HEADING: PL 1989, c. 556, Pt. C, @2 (new))
§2772. Minimum standards
A utilization review program of the applicant must meet the following minimum standards.
[1989, c. 556, Pt. C, §2 (new).]
1. Notification of adverse decisions. Notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated
by the insured within a time period to be determined by the superintendent through rulemaking and must include the name of
the utilization review agent who made the decision.
[1993, c. 602, §5 (amd).]
2. Reconsideration of determinations. All licensees shall maintain a procedure by which insureds, patients or providers may seek reconsideration of determinations
of the licensee.
[1989, c. 556, Pt. C, §2 (new).]
3. Accessibility of representatives. A representative of the licensee must be accessible by telephone to insureds, patients or providers and the superintendent
may adopt standards of accessability by rule.
[1989, c. 556, Pt. C, §2 (new).]
3-A. Medical utilization review criteria. The licensee must have written medical utilization review criteria to be employed in the review process. The criteria must
be available for review as a part of any review conducted pursuant to section 2774, subsection 1 and a copy of the criteria
must be provided to the bureau upon request.
[1995, c. 332, Pt. M, §7 (new).]
4. Information materials; confidentiality. A copy of the materials designed to inform applicable 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 must be filed with the bureau.
[1989, c. 556, Pt. C, §2 (new).]
5. Penalty for noncompliance with utilization review programs. A medical utilization review program may not recommend or implement a penalty of more than $500 for failure to provide notification.
This subsection does not limit the right of insurers to deny a claim when appropriate prospective or retroactive review concludes
that services or treatment rendered were not medically necessary.
[1995, c. 332, Pt. M, §8 (amd).]
6. Prohibited activities. A medical utilization review entity shall ensure that an employee does not perform medical utilization review services involving
a health care provider or facility in which that employee has a financial interest.
[RR 1993, c. 2, §15 (rnu).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2773. Utilization review services
Title 24-A: MAINE INSURANCE CODE
Chapter 34: LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES (HEADING: PL 1989, c. 556, Pt. C, @2 (new))
§2773. Utilization review services
As used in this chapter, unless the context indicates otherwise, "utilization review services" or "medical utilization review
services" means a program or process by which a person, partnership or corporation, on behalf of an insurer, nonprofit service
organization, 3rd-party administrator, health maintenance organization, preferred provider organization or employer that is
a payor for or that arranges for payment of medical services, seeks to review the utilization, appropriateness or quality
of medical services provided to a person whose medical services are paid for, partially or entirely, by that insurer, nonprofit
service organization, 3rd-party administrator, health maintenance organization, preferred provider organization or employer.
The terms include these programs or processes whether they apply prospectively or retrospectively to medical services. Utilization
review services include, but are not limited to, the following:
[1993, c. 602, §7 (amd).]
1. Second opinion programs. Second opinion programs;
[1989, c. 556, Pt. C, §2 (new).]
2. Prehospital admission certification. Prehospital admission certification;
[1989, c. 556, Pt. C, §2 (new).]
3. Preinpatient service eligibility certification. Preinpatient service eligibility certification; and
[1989, c. 556, Pt. C, §2 (new).]
4. Concurrent hospital review. Concurrent hospital review to determine appropriate length of stay.
[1989, c. 556, Pt. C, §2 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2774. Enforcement
Title 24-A: MAINE INSURANCE CODE
Chapter 34: LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES (HEADING: PL 1989, c. 556, Pt. C, @2 (new))
§2774. Enforcement
The following provisions govern enforcement of this chapter.
[1989, c. 556, Pt. C, §2 (new).]
1. Periodic reviews. The superintendent may conduct periodic reviews of the operations of the entities licensed pursuant to this chapter to ensure
that they continue to meet the minimum standards set forth in section 2772 and any applicable rules adopted by the superintendent.
The superintendent may perform periodic telephone audits of licensees to determine if representatives of the licensee are
reasonably accessible, as required by section 2772.
[1989, c. 556, Pt. C, §2 (new).]
2. Action against licensee. The superintendent is authorized to take appropriate action against a licensee which fails to meet the standards of this
chapter or any rules adopted by the superintendent, or who fails to respond in a timely manner to corrective actions ordered
by the superintendent. The superintendent may impose a civil penalty not to exceed $1,000 for each violation, as permitted
by section 12-A, or may deny, suspend or revoke the license.
[1989, c. 556, Pt. C, §2 (new).]
3. Opportunity to provide information and request hearing. Before taking the actions authorized by this section to deny, suspend or revoke the license, the superintendent shall provide
the licensee with reasonable time to supply additional information demonstrating compliance with the requirements of this
chapter and the opportunity to request a hearing to be held consistent with the provisions of the Maine Administrative Procedure
Act, Title 5, chapter 375.
[1989, c. 556, Pt. C, §2 (new).]
4. Authority to adopt rules. The superintendent may adopt rules necessary to implement the provisions of this chapter.
[1989, c. 556, Pt. C, §2 (new).]
5. Rulings on appropriateness of medical judgments not authorized. Nothing in this chapter requires or authorizes the superintendent to rule on the appropriateness of medical decisions or
judgments rendered by review entities and their agents.
[1989, c. 556, Pt. C, §2 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
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