Title 27, Title 27 Title 27

Adopted pursuant to this chapter; (a) The office may deny a certificate or certification upon review of the application if, upon review of the application, it finds that the applicant proposing to conduct utilization review does not meet the standards required by this chapter or …

For the purposes of this chapter, in addition to the provisions of § 27-18.9-13, a healthcare entity and/or review agent or any person or entity conducting any activities requiring certification under this chapter shall be subject to the penalty and enforcement provisions of this…

If any provision of this chapter or the application of any provision to any person or circumstance shall be held invalid, that invalidity shall not affect the provisions or application of this chapter which can be given effect without the invalid provision or application, and to …

(a) The purpose of this chapter is to authorize a three-year (3) pilot program whereby, except as provided in subsection (b), an insurer shall not impose a prior authorization requirement for any admission, item, service, treatment, or procedure ordered by a primary care provider…

As used in this chapter, the following terms are defined as follows: (1) “Adverse benefit determination” means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a…

(a) A review agent shall not conduct benefit determination reviews in the state unless the office has granted the review agent a certificate. (b) Individuals shall not be required to hold a separate review agent certification under this chapter when acting as either an employee o…

An application for review agent certification or recertification shall include, but is not limited to, documentation to evidence the following: (a) Administrative and non-administrative benefit determinations. (1) That the healthcare entity or its review agent provide beneficiari…

(a) Procedural failure by claimant. (1) In the event of the failure of the claimant or an authorized representative to follow the healthcare entities claims procedures for a pre-service claim, the healthcare entity or its review agent must: (i) Notify the claimant or the authoriz…

(a) Benefit determination notification timelines. A healthcare entity and/or its review agent shall comply with the following: (1) For urgent or emergent healthcare services, benefit determinations (adverse or non-adverse) shall be made as soon as possible taking into account exi…

(a) Administrative and non-administrative appeals. The review agent shall conform to the following for the internal appeal of administrative or non-administrative adverse benefit determinations: (1) The review agent shall maintain and make available a written description of its a…

(a) General requirements. (1) In cases where the non-administrative adverse benefit determination or the final internal level of appeal to reverse a non-administrative adverse benefit determination is unsuccessful, the healthcare entity or review agent shall provide for an extern…

The office shall establish reporting requirements to determine if adverse benefit determination and/or utilization review programs are in compliance with the provisions of this chapter and applicable regulations as well as in compliance with applicable federal law.