Title 58 — INSURANCE

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…

A step therapy override exception shall be approved by a health carrier, health benefit plan, or utilization review organization if any of the following circumstances apply: (1) The prescription drug required under the step therapy protocol is contraindicated pursuant to the drug…

Nothing in §§ 58-17H-53 to 55-17H-56 shall be construed to prevent: (1) A health carrier, health benefit plan, or utilization review organization from requiring a covered person to try a prescription drug with the same generic name and demonstrated bioavailability or biological p…

Coverage of in-network emergency services are subject to applicable copayments, coinsurance, and deductibles. Source: SL 2011, ch 219 , § 31. 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…

Cost-sharing requirements for out-of-network emergency services expressed as a copayment amount or coinsurance rate imposed with respect to a covered person cannot exceed the cost-sharing requirement imposed with respect to a covered person if the services were provided in-networ…

Notwithstanding § 58-17H-7 , a covered person may be required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of-network provider charges over the amount the health carrier is required to pay pursuant to this section. A health carrier complies…

For capitated or other health benefit plans that do not have a negotiated per-service amount for in-network providers, subdivision 58-17H-8 (1) does not apply. Source: SL 2011, ch 219 , § 34. Commission Note: SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of the 20…

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…

Prior to issuing a decision in accordance with the timeframes provided in § 58-17I-9 , the health carrier shall provide free of charge to covered person, or the covered person's authorized representative, any new or additional evidence, relied upon or generated by the health carr…

The decision issued pursuant to § 58-17I-9 shall set forth in a manner calculated to be understood by the covered person or, if applicable, the covered person's authorized representative and include the following: (1) The titles and qualifying credentials of any person participat…

Each health carrier shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination. In addition, a health carrier shall provide expedited review of a grievance involving an adverse determination with respect to…

In an expedited review that is not an initial determination for benefits, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or, if applicable, the covered person's authorized representative, …

An expedited review decision, that is not an initial determination for benefits, shall be made and the covered person or, if applicable, the covered person's authorized representative, shall be notified of the decision in accordance with § 58-17I-15 as expeditiously as the covere…

A notification of a decision under §§ 58-17I-12 to 58-17I-15 , inclusive, shall, in a manner calculated to be understood by the covered person or, if applicable, the covered person's authorized representative, set forth the following: (1) The titles and qualifying credentials of …