Title 58 — INSURANCE

Terms used in this chapter mean: (1) "Adverse determination," any of the following: (a) A determination by a health carrier or the carrier's designee utilization review organization that, based upon the information provided, a request by a covered person for a benefit under the h…

If a health benefit plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in subdivision 58-17H-8 (1) is the median of these negotiated amounts. Source: SL 2011, ch 219 , § 35. Commission Note: SL 2012, ch 239, § 1 provid…

Any cost-sharing requirement other than a copayment or coinsurance requirement, such as a deductible or out-of-pocket maximum, may be imposed with respect to emergency services provided out-of-network if the cost-sharing requirement generally applies to out-of-network benefits. A…

For immediately required post-evaluation or post-stabilization services, a health carrier shall provide access to a designated representative twenty-four hours a day, seven days a week, to facilitate review, or otherwise provide coverage with no financial penalty to the covered p…

If the director and the secretary find that the requirements of any private accrediting body meet the requirements of coverage of emergency medical services as set forth in §§ 58-17H-4 to 58-17H-12 , inclusive, the health carrier may, at the discretion of the director and secreta…

A health carrier is responsible for monitoring all utilization review activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of this chapter and applicable rules are met. The health carrier shall also ensure that appropriate personne…

If a health carrier contracts to have a utilization review organization or other entity perform the utilization review functions required by this chapter, or applicable rules, the director shall hold the health carrier responsible for monitoring the activities of the utilization …

A health carrier that requires a request for benefits under the covered person's health plan to be subjected to utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated for the filing of benefit …

A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health carrier may develop its own clinical review criteria, or it may purchase or license clinical re…

Qualified licensed health care professionals shall administer the utilization review program and oversee review decisions. Any adverse determination shall be evaluated by an appropriately licensed and clinically qualified health care provider. Source: SL 2011, ch 219 , § 43. Comm…

A health carrier shall issue utilization review and benefit determinations in a timely manner pursuant to the requirements of §§ 58-17H-27 to 58-17H-32 , inclusive, and §§ 58-17H-40 to 58-17H-48 , inclusive. A health carrier shall have a process to ensure that utilization reviewe…

For the purposes of this chapter, the term, health benefit plan, means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. The term inc…

Any health carrier shall routinely assess the effectiveness and efficiency of its utilization review program. Source: SL 2011, ch 219 , § 45. Commission Note: SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Pa…

Any health carrier's data system shall be sufficient to support utilization review program activities and to generate management reports to enable the health carrier to monitor and manage health care services effectively. Source: SL 2011, ch 219 , § 46. Commission Note: SL 2012, …

If a health carrier delegates any utilization review activities to a utilization review organization, the health carrier shall maintain adequate oversight, which shall include: (1) A written description of the utilization review organization's activities and responsibilities, inc…

Each health carrier shall coordinate the utilization review program with other medical management activity conducted by the carrier, such as quality assurance, credentialing, provider contracting data reporting, grievance procedures, processes for assessing member satisfaction, a…

Each health carrier shall provide covered persons and participating providers with access to its review staff by a toll-free number or collect call telephone line. Source: SL 2011, ch 219 , § 49. Commission Note: SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of th…

If conducting a utilization review, the health carrier shall collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit determination. Source: SL 2011, ch 219 , § 50. Commission Note: SL 2012, ch 239, § 1 provides: …

In conducting utilization review, the health carrier shall ensure that the review is conducted in a manner to ensure the independence and impartiality of the individuals involved in making the utilization review or benefit determination. In ensuring the independence and impartial…

A health carrier shall maintain written procedures pursuant to this chapter, for making standard utilization review and benefit determinations on requests submitted to the health carrier by covered persons or their authorized representatives for benefits and for notifying covered…

For any prospective review determination, other than allowed by this section, a health carrier shall make the determination and notify the covered person or, if applicable, the covered person's authorized representative of the determination, whether the carrier certifies the prov…

For concurrent review determinations, if a health carrier has certified an ongoing course of treatment to be provided over a period of time or number of treatments: (1) Any reduction or termination by the health carrier during the course of treatment before the end of the period …

For the purposes of this chapter, the term, urgent care request means a request for a health care service or course of treatment with respect to which the time periods for making a nonurgent care request determination: (1) Could seriously jeopardize the life or health of the cove…

For retrospective review determinations, the health carrier shall make the determination within a reasonable period of time, but in no event later than thirty days after the date of receiving the benefit request. In the case of a certification, the health carrier may notify in wr…

For purposes of calculating the time periods within which a determination is required to be made for prospective and retrospective reviews, the time period within which the determination is required to be made begins on the date the request is received by the health carrier in ac…

Any notification of an adverse determination under this section shall, in a manner which is designed to be understood by the covered person, set forth: (1) Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the …

In the certificate of coverage or member handbook provided to covered persons, a health carrier shall include a clear and comprehensive description of its utilization review procedures, including the procedures for obtaining review of adverse determinations, and a statement of ri…

If the director and the secretary find that the requirements of any private accrediting body meet the requirements of utilization review as set forth in this chapter, the health carrier may, at the discretion of the director and secretary, be deemed to have met the applicable req…

Any utilization review organization which engages in utilization review activities in this state shall register with the Division of Insurance prior to conducting business in this state. The registration shall be in a format prescribed by the director. In prescribing the form or …

Any utilization review organization which has previously registered in this state shall, on or before July first of each year, file with the Division of Insurance any changes to the initial or subsequent annual registration for the utilization review organization. Source: SL 2011…

The director or the secretary may request information from any utilization review organization at any time pertaining to its activities in this state. The utilization review organization shall respond to all requests for information within twenty days. Source: SL 2011, ch 219 , §…

A utilization review organization may not engage in utilization review in this state unless the utilization review organization is properly registered. The director may issue a cease and desist order against any utilization review organization which fails to comply with the requi…

The director may require the payment of a fee in conjunction with the initial or annual registration of a utilization review organization not to exceed two hundred fifty dollars per registration. The fee shall be established by rules promulgated pursuant to chapter 1-26 . Source:…

The provisions of this chapter apply to any health carrier that provides or performs utilization review services. The requirements of this chapter also apply to any designee of the health carrier or utilization review organization that performs utilization review functions on the…

Each health carrier shall establish written procedures, in accordance with §§ 58-17H-40 to 58-17H-48 , inclusive, for receiving benefit requests from covered persons or their authorized representatives and for making and notifying covered persons or their authorized representativ…

If the covered person or, if applicable, the covered person's authorized representative has failed to provide sufficient information for the health carrier to make a determination, the health carrier shall notify the covered person or, if applicable, the covered person's authoriz…

If the benefit request involves a prospective review urgent care request, the provisions of § 58-17H-41 apply only in the case of a failure that: (1) Is a communication by a covered person or, if applicable, the covered person's authorized representative, that is received by a pe…

For an urgent care request, unless the covered person or the covered person's authorized representative has failed to provide sufficient information for the health carrier to determine whether, or to what extent, the benefits requested are covered benefits or payable under the he…

The health carrier shall provide the covered person or, if applicable, the covered person's authorized representative, a reasonable period of time to submit the necessary information, taking into account the circumstances, but in no event less than forty-eight hours after the dat…

The health carrier shall notify the covered person or, if applicable, the covered person's authorized representative, of its determination with respect to the urgent care request as soon as possible, but in no event more than forty-eight hours after the earlier of: (1) The health…

For concurrent review urgent care requests involving a request by the covered person or the covered person's authorized representative to extend the course of treatment beyond the initial period of time or the number of treatments, if the request is made at least twenty-four hour…

For purposes of calculating the time periods within which a determination is required to be made under §§ 58-17H-43 to 58-17H-45 , inclusive, the time period within which the determination is required to be made shall begin on the date the request is filed with the health carrier…

If a health carrier's determination with respect to §§ 58-17H-40 to 58-17H-47 , inclusive, is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with this section. A notification of an adverse determination under this sect…

The director may, after consultation with the secretary, promulgate rules, pursuant to chapter 1-26 , to carry out the provisions of this chapter. The rules shall provide for a timely administration of utilization review by the public and assure that utilization review decisions …

If conducting utilization review or making a benefit determination for emergency services, a health carrier that provides benefits for services in an emergency department of a hospital shall comply with the provisions of §§ 58-17H-5 to 58-17H-13 , inclusive. A health carrier shal…

Any health benefit plan as defined in § 58-17H-2 that provides benefits for injected or intravenously administered cancer treatment medication used to kill or slow the growth of cancerous cells shall provide no less favorable benefits for prescribed, orally administered anticance…

A health carrier may not reclassify benefits with respect to cancer treatment medications or increase a copayment, deductible, or coinsurance amount for covered cancer treatment medications that are injected or intravenously administered unless: (1) The increase is applied genera…

Nothing in §§ 58-17H-50 and 58-17H-51 prohibits a health carrier from performing medical management practices that comply with the provisions of this chapter. Source: SL 2015, ch 252 , § 3, eff. Jan. 1, 2016.

A health carrier, health benefit plan, or utilization review organization shall consider available recognized evidence-based and peer-reviewed clinical practice guidelines when establishing a step therapy protocol. Upon written request of a covered person, a health carrier, healt…

When coverage of a prescription drug for the treatment of any medical condition is restricted for use by a health carrier, health benefit plan, or utilization review organization through the use of a step therapy protocol, the covered person and the prescribing health care profes…