Title 58 — INSURANCE

Terms used in this chapter mean: (1) "Utilization review," a review of health care services provided or to be provided to an individual to assist in the determination of the nature of the injury or condition, or the appropriateness of the treatment provided or to be provided; (2)…

A utilization review organization that conducts utilization reviews solely for property and casualty insurers in this state pursuant to policies issued in this state is not subject to chapters 58-17F , 58-17G , 58-17H , and 58-17I except that any such utilization review organizat…

Any property and casualty insurer seeking utilization review with respect to an insurance contract issued in this state may only use a utilization review organization registered pursuant to this chapter. Source: SL 2002, ch 231 , § 3.

Any utilization review pursuant to this chapter shall be administered by a qualified licensed health care professional. Any adverse determination shall be evaluated by an appropriately licensed and clinically qualified health care professional. Any utilization review evaluation s…

No utilization review organization may base its fees or charges on any recommendation for reduction in payment under an insurance contract or on a percentage of claim savings. Source: SL 2002, ch 231 , § 5.

An insurer that denies, in whole or in part, a policyholder's claim after consideration of a utilization review shall provide the policyholder with an opportunity to request reconsideration and to submit additional information relating to the claim. Source: SL 2002, ch 231 , § 6.

Nothing in this chapter is intended to create or abrogate any cause of action as a result of a violation of the standards in this chapter. Source: SL 2002, ch 231 , § 7.