Title 20, Insurance

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, proto…

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 chap…

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 meet…

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 denta…

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 purpo…

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…

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 agen…

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 …

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 …

A. Each utilization review agent shall: 1. Adopt a written utilization review plan with standards and criteria that apply to all utilization review determinations and that are objective, clinically valid and compatible with established principles of health care. 2. Establish the …

A. No minimum dollar amount may be imposed on any claim that is the subject of an adverse determination for a member to, and any member who receives an adverse determination may, pursue the applicable review process prescribed in this article. Except as provided in sections 20-25…

A. Except for a denial of a claim for service or a rescission of coverage, any member who receives an adverse determination may pursue an expedited medical review of that denial if the member's treating provider certifies in writing and provides supporting documentation to the ut…

A. Any member who receives an adverse determination and who does not qualify for an expedited medical review pursuant to section 20-2534 may request, either orally or in writing, an initial appeal of that denial by notifying the person described in section 20-2533, subsection H, …

A. For a group health plan, or a grandfathered individual plan, if a health care insurer elects to include as part of its internal review levels a voluntary internal appeal level after any applicable initial appeal pursuant to section 20-2535 and the utilization review agent deni…

(Conditionally Rpld.) A. If the utilization review agent denies the member's request for a covered service or claim for a covered service at all applicable internal levels of review or if the member has exhausted the health care insurer's internal levels of review pursuant to sec…

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 pro…

The director may adopt rules pursuant to title 41, chapter 6 to carry out this article.

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 departme…

The director may assess each health care insurer that is authorized to transact insurance: 1. A single fee of not more than $200 per insurer. 2. Up to $200 each year for the costs of performing the responsibilities relating to the procurement of independent review organizations a…

A health care insurer and an independent review organization shall maintain all records related to internal and external appeals and exception requests for at least three years after the completion of the appeals process or exception request process.