Chapter 238
2005 -- H 6483
SUBSTITUTE A
Enacted 07/09/05
A N A C T
RELATING TO
HEALTH CARE SERVICES -- UTILIZATION REVIEW ACT
Introduced By:
Representatives Costantino, Carter, and Slater
Date
Introduced: May 11, 2005
It is enacted by the General Assembly as
follows:
SECTION 1.
Sections 23-17.12-3, 23-17.12-4, 23-17.12-5, 23-17.12-6, 23-17.12-8, 23-
17.12-9 and 23-17.12-10 of the General Laws in
Chapter 23-17.12 entitled "Health Care Services
-
Utilization
Review Act" are hereby amended to read as follows:
-
23-17.12-3. Regulation
of review agents -- Certificate. General certificate
requirements. -- (a) A review agent
shall not conduct utilization review in the state unless the
department has granted the review agent a
certificate.
(b) Review
agents who are operating in Rhode Island prior to the promulgation of
regulations pursuant to this chapter may
continue to conduct utilization review until the time that
the department promulgates regulations, develops
required forms, and has acted on the
application submitted by the review agent.
(c) (b)
Individuals shall not be required to hold separate certification under this
chapter
when acting as either an employee of, an affiliate
of, a contractor for, or otherwise acting on
behalf of a certified review agent.
(d) (c)
The department shall issue a certificate to an applicant that has met the
minimum
standards established by this chapter, and
regulations promulgated in accordance with it,
including the payment of any fees as required,
and other applicable regulations of the department.
(e) (d)
A certificate issued under this chapter is not transferable, and the transfer
of fifty
percent (50%) or more of the ownership of a
review agent shall be deemed a transfer.
(f) (e)
After consultation with the payers and providers of health care, the department
shall adopt regulations necessary to implement
the provisions of this chapter. including, but not
limited to, the following:
(1) The
requirement that the review agent provide patients and providers with a summary
of its utilization review plan including a
summary of the standards, procedures and methods to be
used in evaluating proposed or delivered health
care services;
(2) The
circumstances, if any, under which utilization review may be delegated to any
other utilization review program and evidence
that the delegated agency is a certified utilization
review agency pursuant to the requirements of
this chapter;
(3) A
complaint resolution process, acceptable to the department whereby patients,
their
physicians, or other health care providers may
seek prompt reconsideration or appeal of adverse
decisions by the review agent, as well as the
resolution of complaints and other matters of which
the review agent has received written notice;
(4) The type
and qualifications of personnel authorized to perform utilization review,
including a requirement that only a practitioner
with the same status as the ordering practitioner,
or a licensed physician or dentist, is permitted
to make a prospective or concurrent adverse
determination;
(5) The
requirement that each review agent shall utilize and provide, as determined
appropriate by the director, to Rhode Island
licensed hospitals and the RI Medical Society, in
either electronic or paper format, written
medically acceptable screening criteria and review
procedures which are established and
periodically evaluated and updated with appropriate
consultation with Rhode Island licensed
physicians, hospitals, including practicing physicians,
and other health care providers in the same
specialty as would typically treat the services subject
to the criteria as follows:
(i) Utilization
review agents shall consult with no fewer than five (5) Rhode Island
licensed physicians or other health care
providers. Further, in instances where the screening
criteria and review procedures are applicable to
inpatients and/or outpatients of hospitals, the
medical director of each licensed hospital in
Rhode Island shall also be consulted. Utilization
review agents who utilize screening criteria and
review procedures provided by another entity
may satisfy the requirements of this section if
the utilization review agent demonstrates to the
satisfaction of the director that the entity
furnishing the screening criteria and review procedures
has complied with the requirements of this
section.
(ii)
Utilization review agents seeking initial certification shall conduct the
consultation
for all screening and review criteria to be
utilized. Utilization review agents who have been
certified for one year or longer shall be
required to conduct the consultation on a periodic basis
for the utilization review agent's highest
volume services subject to utilization review during the
prior year; services subjected to the highest
volume of adverse determinations during the prior
year; and for any additional services identified
by the director.
(iii)
Utilization review agents shall not include in the consultations as required
under
paragraph (i) of this subdivision, any
physicians or other health services providers who have
financial relationships with the utilization
review agent other than financial relationships for
provision of direct patient care to utilization
review agent enrollees and reasonable compensation
for consultation as required by paragraph (i) of
this subdivision.
(iv) All
documentation regarding required consultations, including comments and/or
recommendations provided by the health care
providers involved in the review of the screening
criteria, as well as the utilization review
agent's action plan or comments on any
recommendations, shall be in writing and shall
be furnished to the department on request. The
documentation shall also be provided on request
to any licensed health care provider at a nominal
cost that is sufficient to cover the utilization
review agent's reasonable costs of copying and
mailing.
(v)
Utilization review agents may utilize non-Rhode Island licensed physicians or
other
health care providers to provide the
consultation as required under paragraph (i) of this
subdivision, when the utilization review agent
can demonstrate to the satisfaction of the director
that the related services are not currently
provided in Rhode Island or that another substantial
reason requires such approach.
(vi)
Utilization review agents whose annualized data reported to the department
demonstrate that the utilization review agent
will review fewer than five hundred (500) such
requests for authorization may request a
variance from the requirements of this section.
(6) The
requirement that, other than in exceptional circumstances, or when the patient's
attending physician or dentist is not reasonably
available, no adverse determination that care
rendered or to be rendered is medically
inappropriate shall be made until an appropriately
qualified and licensed review physician,
dentist, or other practitioner has spoken to, or otherwise
provided for, an equivalent two-way direct
communication with the patient's attending physician,
dentist, or other practitioner concerning the
medical care;
(7) The
requirement that, upon written request made by or on behalf of a patient, any
determination that care rendered or to be
rendered is medically inappropriate shall include the
written evaluation and findings of the reviewing
physician, dentist, or other practitioner. The
review agent is required to accept a verbal
request made by or on behalf of a patient for any
information where a provider or patient can
demonstrate that a timely response is urgent. The
verbal request must be confirmed, in writing,
within seven (7) days;
(8) The requirement
that a representative of the review agent is reasonably accessible to
patients, patient's family, and providers at
least five (5) days a week during normal business in
Rhode Island and during the hours of the
agency's review operations.
(9) The
policies and procedures to ensure that all applicable state and federal laws to
protect the confidentiality of individual
medical records are followed;
(10) The
policies and procedures regarding the notification and conduct of patient
interviews by the review agent.
(11) The
requirement that no employee of, or other individual rendering an adverse
determination for, a review agent may receive
any financial incentives based upon the number of
denials of certification made by that employee or
individual.
(12) The
requirement that the utilization review agent shall not impede the provision of
health care services for treatment and/or
hospitalization or other use of a provider's services or
facilities for any patient for whom the treating
provider determines the health care service to be of
an emergency nature. The emergency nature of the
health care service shall be documented and
signed by a licensed physician, dentist, or
other practitioner and may be subject to review by a
review agent.
(13) The
requirement that a review agent shall make a determination and shall
communicate that determination within time
frames and by any means specified by the
department; and
(14) The
requirement that except in circumstances as may be allowed by regulations
promulgated pursuant to this chapter, no adverse
determination shall be made on any question
relating to health care and/or medical services
by any person other than an appropriately licensed
physician, dentist, or other practitioner, which
determination shall be discussed by the reviewing
practitioner with the affected provider or other
designated or qualified professional or provider
responsible for treatment of the patient.
(g) (f)
The director of health is authorized to establish any fees for initial
application,
renewal applications, and any other
administrative actions deemed necessary by the director to
implement this chapter.
(h) (g)
The total cost of certification under this title shall be borne by the
certified
entities and shall be one hundred and fifty
percent (150%) of the total salaries paid to the
certifying personnel of the department engaged
in those certifications less any salary
reimbursements and shall be paid to the director
to and for the use of the department. That
assessment shall be in addition to any taxes and
fees otherwise payable to the state.
(h) The
application and other fees required under this chapter shall be sufficient to
pay
for the administrative costs of the certificate
program and any other reasonable costs associated
with carrying out the provisions of this
chapter.
(i) A
certificate expires on the second anniversary of its effective date unless the
certificate is renewed for a two (2) year term
as provided in this chapter.
(j) Any
systemic changes in the review agents operations relative to certification
information on file shall be submitted to the
department for approval within thirty (30) days prior
to implementation.
23-17.12-4. Application.
Application process. -- (a) An applicant for a certificate
requesting certification or recertification shall:
(1) Submit an
application to provided by the director; and
(2) Pay the
application fee established by the director through regulation and section 23-
17.12-3(g)(f).
(b) The
application shall:
(1) Be on a form
and accompanied by supporting documentation that the director
requires; and
(2) Be signed and
verified by the applicant.
(c) Before the
certificate expires, a certificate may be renewed for an additional two (2)
years.
(d) If a
completed application for recertification is being processed by the department,
a
certificate may be continued until a renewal determination
is made.
(c) (e)
In conjunction with the application, the review agent shall submit information
that
the director requires including:
(1) A
utilization review plan that includes:
(i) The
standards and criteria to be utilized by the review agent; provided, however,
that
the agent may A request that the state agency
regard specific portions of the standards and criteria
or the entire document to constitute "trade
secrets" within the meaning of that term in section 38-
2-2(4)(i)(B);
(ii) Those
circumstances, if any, under which utilization review may be delegated to a
provider utilization review program; and
(iii) A
complaint resolution process, consistent with section 23-17.12-9, whereby
patients, physicians, or other health care
providers may seek prompt reconsideration or appeal of
adverse determinations by the review agent as
well as the resolution of other complaints
regarding the review process.
(2) The type and
qualifications of the personnel either employed or under contract to
perform the utilization review;
(3) The
procedures and policies to ensure that a representative of the review agent is
reasonably accessible to patients and providers
five (5) days a week during normal business in
Rhode Island and during the hours of the
agency's review operations;
(4) (2)
The policies and procedures to ensure that all applicable state and federal
laws to
protect the confidentiality of individual
medical records are followed;
(5) (3)
A copy of the materials used to inform enrollees of the requirements under the
health benefit plan for seeking utilization
review or pre-certification and their rights under this
chapter, including information on appealing
adverse determinations.;
(6) (4)
A copy of the materials designed to inform applicable patients and providers of
the requirements of the utilization review plan;
(7) (5)
A list of the third party payers and business entities for which the review
agent is
performing utilization review in this state and
a brief description of the services it is providing for
each client.; and
(8) Evidence
that the review agent has not entered into a compensation agreement or
contract with its employees or agents whereby
the compensation of its employees or its agents is
based upon a reduction of services or the
charges for those services, the reduction of length of
stay, or utilization of alternative treatment
settings; provided nothing in this chapter shall prohibit
agreements and similar arrangements.
(9) (6)
Evidence of liability insurance or of assets sufficient to cover potential
liability.
(d) Any
systemic changes in the review agents operations relative to certification
information on file shall be submitted to the
department for approval within thirty (30) days prior
to implementation.
(e) (f)
The information provided must demonstrate that the review agent will comply
with the regulations adopted by the director
under this chapter.
(f) The
application and other fees required under this chapter shall be sufficient to
pay
for the administrative costs of the certificate
program and any other reasonable costs associated
with carrying out the provisions of this chapter.
23-17.12-5. Renewal
of certificate. General application requirements. -- (a) A
certificate expires on the second anniversary of
its effective date unless the certificate is renewed
for a two (2) year term as provided in this
section.
(b) Before the
certificate expires, a certificate may be renewed for an additional two (2)
year term if the applicant:
(1) Otherwise
is entitled to the certificate;
(2) Pays to
the director the renewal fee set by the director through regulation consistent
with section 23-17.12-3(g); and
(3) Submits to
the director:
(i) A renewal
application on the form that the director requires; and
(ii)
Satisfactory evidence of compliance with any requirements under this chapter
for
certificate renewal.
(c) If the
requirements of this section are met, the director shall renew a certificate.
(d) If a
completed application is being processed by the department, a certificate may
be
continued until a renewal determination is made.
An application
for certification or recertification shall be accompanied by documentation
to evidence the following:
(a) The
requirement that the review agent provide patients and providers with a summary
of its utilization review plan including a
summary of the standards, procedures and methods to be
used in evaluating proposed or delivered health
care services;
(b) The
circumstances, if any, under which utilization review may be delegated to any
other utilization review program and evidence
that the delegated agency is a certified utilization
review agency pursuant to the requirements of
this chapter;
(c) A complaint
resolution process, consistent with section 23-17.12-9 and acceptable to
the department, whereby patients, their physicians,
or other health care providers may seek
prompt reconsideration or appeal of adverse
decisions by the review agent, as well as the
resolution of complaints and other matters of
which the review agent has received written notice;
(d) The type
and qualifications of personnel (employed or under contract) authorized to
perform utilization review, including a
requirement that only a practitioner with the same status
as the ordering practitioner, or a licensed
physician or dentist, is permitted to make a prospective
or concurrent adverse determination;
(e) The
requirement that a representative of the review agent is reasonably accessible
to
patients, patient's family and providers at
least five (5) days a week during normal business in
Rhode Island and during the hours of the
agency's review operations;
(f) The
policies and procedures to ensure that all applicable state and federal laws to
protect the confidentiality of individual
medical records are followed;
(g) The
policies and procedures regarding the notification and conduct of patient
interviews by the review agent;
(h) The
requirement that no employee of, or other individual rendering an adverse
determination for, a review agent may receive any
financial incentives based upon the number of
denials of certification made by that employee
or individual;
(i) The
requirement that the utilization review agent shall not impede the provision of
health care services for treatment and/or
hospitalization or other use of a provider's services or
facilities for any patient for whom the treating
provider determines the health care service to be of
an emergency nature. The emergency nature of the
health care service shall be documented and
signed by a licensed physician, dentist or other
practitioner and may be subject to review by a
review agent;
(j) Evidence
that the review agent has not entered into a compensation agreement or
contract with its employees or agents whereby
the compensation of its employees or its agents is
based upon a reduction of services or the
charges for those services, the reduction of length of
stay, or utilization of alternative treatment
settings; provided, nothing in this chapter shall prohibit
agreements and similar arrangements; and
(k) An adverse
determination and internal appeal process as required by this chapter.
23-17.12-6.
Denial, suspension, or revocation of certificate. -- (a) The department
may
deny a certificate 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 by any regulations promulgated
pursuant to this chapter.
(b) The department
may revoke a certificate and/or impose reasonable monetary
penalties not to exceed five thousand dollars
($5,000) per violation in any case in which:
(1) The review
agent fails to comply substantially with the requirements of this chapter
or of regulations adopted pursuant to this
chapter;
(2) The review
agent fails to comply with the criteria used by it in its application for a
certificate; or
(3) The review
agent refuses to permit examination by the director to determine
compliance with the requirements of this chapter
and regulations promulgated pursuant to the
authority granted to the director in this
chapter; provided, however, that the examination shall be
subject to the confidentiality and "need to
know" provisions of subdivisions
23-17.12-9(16)(c)(4)
and (5). These determinations may involve consideration
of any written grievances filed with the
department against the review agent by patients
or providers.
(c) Any applicant
or certificate holder aggrieved by an order or a decision of the
department made under this chapter without a
hearing may, within thirty (30) days after notice of
the order or decision, make a written request to
the department for a hearing on the order or
decision pursuant to section 42-35-15.
(d) The procedure
governing hearings authorized by this section shall be in accordance
with sections 42-35-9 -- 42-35-13 as stipulated
in section 42-35-14(a). A full and complete record
shall be kept of all proceedings, and all
testimony shall be recorded but need not be transcribed
unless the decision is appealed pursuant to
section 42-35-15. A copy or copies of the transcript
may be obtained by any interested party upon
payment of the cost of preparing the copy or
copies. Witnesses may be subpoenaed by either
party.
23-17.12-8.
Waiver of requirements. -- (a) Except for utilization review activities
performed to determine the necessity and
appropriateness of substance abuse and mental health
care, treatment or services, the department
shall waive all the requirements of this chapter, with
the exception of those contained in sections
23-17.12-9, (a)(1)-(3), (5), (6), (8), (b)(1)-(6), and
C(2)-(6), 23-17.12-12, and 23-17.12-14, for a review
agent that has received, maintains and
provides evidence to the department of
accreditation from the utilization review accreditation
commission (URAC) or other organization approved
by the director. The waiver shall be
applicable only to those services that are
included under the accreditation by the utilization
review accreditation commission or other
approved organization.
(b) The
department shall waive the requirements of this chapter only when a direct
conflict exists with those activities of a
review agent that are conducted pursuant to contracts with
the state or the federal government or those
activities under other state or federal jurisdictions.
23-17.12-9. Decisions
and internal appeals. Review agency requirement for adverse
determination and internal appeals. – (a) The decision
and appeals process of the review agent
shall conform to the following:
(1) Notification
of a prospective determination by the review agent shall be mailed or
otherwise communicated to the provider of record
and to the patient or other appropriate
individual within one business day of the
receipt of all information necessary to complete the
review unless otherwise determined by the
department in regulation for nonurgent and
nonemergency services.
(2) Notification
of a concurrent determination shall be mailed or otherwise
communicated to the patient and to the provider
of record prior to the end of the current certified
period consistent with time frames to be
established in regulations promulgated by the
department.
(3) (i)
Notification of a retrospective determination shall be mailed or otherwise
communicated to the patient and to the provider
of record within thirty (30) business days of
receipt of a request for payment with all
supporting documentation for the covered benefit being
reviewed.
(4) A
utilization review agency shall not retrospectively deny coverage for
health care
services provided to a covered person when prior
approval has been obtained from the review
agent unless the approval was based upon inaccurate
information material to the review or the
health care services were not provided
consistent with the provider's submitted plan of care
and/or any restrictions included in the prior
approval granted by the review agent.
(ii) (5)
Any notice of a determination not to certify a health care service shall be
made,
documented, and signed and shall be mailed or
otherwise communicated, and shall include:
(A) (i)
The principal reasons for the determination, and
(B) (ii)
The procedures to initiate an appeal of the determination or the name and
telephone number of the person to contract with
regard to an appeal.
(6) All initial
retrospective adverse determinations of a health care service that had been
ordered by a physician, dentist or other
practitioner shall be made, documented and signed
consistent with the regulatory requirements
which shall be developed by the department with the
input of review agents, providers and other
affected parties.
(7) The requirement
that, other than in exceptional circumstances, or when the patient's
attending physician or dentist is not reasonably
available, no adverse determination that care
rendered or to be rendered is medically
inappropriate shall be made until an appropriately
qualified and licensed review physician, dentist
or other practitioner has spoken to, or otherwise
provided for, an equivalent two-way direct
communication with the patient's attending physician,
dentist, other practitioner, other designated or
qualified professional or provider responsible for
treatment of the patient concerning the medical
care.
(8) All
initial, prospective and concurrent adverse determinations of a health care
service
that had been ordered by a physician, dentist or
other practitioner shall be made, documented and
signed by a licensed practitioner with the same
licensure status as the ordering practitioner or a
licensed physician or dentist.
(9) The
requirement that except in circumstances as may be allowed by regulations
promulgated pursuant to this chapter, no adverse
determination shall be made on any question
relating to health care and/or medical services
by any person other than an appropriately licensed
physician, dentist or other practitioner.
(10) The
requirement that, upon written request made by or on behalf of a patient, any
determination that care rendered or to be
rendered is medically inappropriate shall include the
written evaluation and findings of the reviewing
physician, dentist or other practitioner. The
review agent is required to accept a verbal
request made by or on behalf of a patient for any
information where a provider or patient can
demonstrate that a timely response is urgent. The
verbal request must be confirmed, in writing, within
seven (7) days.
(b) The review
agent shall conform to the following for the appeal of an adverse
determination:
(4) (1)
The review agent shall maintain and make available a written description of the
appeal procedure by which either the patient or
the provider of record may seek review of
determinations not to certify a health care
service. The process established by each review agent
may include a reasonable period within which an
appeal must be filed to be considered and that
period shall not be less than sixty (60) days.
(5) (2)
The review agent shall notify, in writing, the patient and provider of record
of its
decision on the appeal as soon as practical, but
in no case later than fifteen (15) or twenty-one
(21) working days if verbal notice is given
within fifteen (15) working days after receiving the
required documentation on the appeal.
(6) (3)
The review agent shall also provide for an expedited appeals process for
emergency or life threatening situations. Each
review agent shall complete the adjudication of
expedited appeals within two (2) business days
of the date the appeal is filed and all information
necessary to complete the appeal is received by
the review agent.
(7) All
initial, prospective, and concurrent adverse determinations of a health care
service that had been ordered by a physician,
dentist, or other practitioner shall be made,
documented, and signed by a licensed
practitioner with the same licensure status as the ordering
practitioner or a licensed physician or dentist.
(8) (4)
In cases where an initial appeal to reverse an adverse determination is
unsuccessful, the review agent shall assure that
a licensed practitioner with the same licensure
status as the ordering practitioner or a
licensed physician in the same or a similar general
specialty as typically manages the medical
condition, procedure, or treatment under discussion
conducts the next level of review.
(9) (5)
The review agent shall maintain records of written appeals and their
resolution,
and shall provide reports as requested by the
department.
(10) The
department may, in response to a complaint that is provided in written form to
the review agent, review an appeal regarding any
adverse determination, and may request
information of the review agent, provider, or
patient regarding the status, outcome, or rationale
regarding the decision.
(11) All
initial retrospective adverse determinations of a health care service that had
been
ordered by a physician, dentist, or other
practitioner shall be made, documented, and signed
consistent with the regulatory requirements
which shall be developed by the department with the
input of review agents, providers, and other
affected parties.
(12) (6)
All first level appeals of determinations not to certify a health care service
that
had been ordered by a physician, dentist, or
other practitioner shall be made, documented, and
signed by a licensed practitioner with the same
licensure status as the ordering practitioner or a
licensed physician or a licensed dentist.
(c) The review
agency must conform to the following requirements when making its
adverse determination and appeal decisions:
(13) (1)
The review agent must assure that the licensed practitioner or licensed
physician
required in subdivision (11) is reasonably available
to review the case as required under
subsection 23-17.12-3(f)(e).
(14) (2)
No reviewer at any level under this section shall be compensated or paid a
bonus
or incentive based on making or upholding an
adverse determination.
(15) (3)
No reviewer under this section who has been involved in prior reviews of the
case under appeal or who has participated in the
direct care of the patient may participate as the
sole reviewer in reviewing a case under appeal;
provided, however, that when new information
has been made available at the first level of
appeal, then the review may be conducted by the
same reviewer who made the initial adverse
determination.
(16) (i) (4)
A review agent is only entitled to review information or data relevant to the
utilization review process. A review agent may
not disclose or publish individual medical records
or any confidential medical information obtained
in the performance of utilization review
activities. A review agent shall be considered a
third party health insurer for the purposes of
section 5-37.3-6(b)(6) of this state and shall
be required to maintain the security procedures
mandated in section 5-37.3-4(c).
(ii) (5)
Notwithstanding any other provision of law, the review agent, the department,
and all other parties privy to information which
is the subject of this chapter shall comply with all
state and federal confidentiality laws, including,
but not limited to, chapter 37.3 of title 5
(Confidentiality of Health Care Communications
and Information Act) and specifically section 5-
37.3-4(c), which requires limitation on the
distribution of information which is the subject of this
chapter on a "need to know" basis, and
section 40.1-5-26.
(6) The
department may, in response to a complaint that is provided in written form to
the
review agent, review an appeal regarding any
adverse determination, and may request
information of the review agent, provider or
patient regarding the status, outcome or rationale
regarding the decision.
(d) The
requirement that each review agent shall utilize and provide, as determined
appropriate by the director, to Rhode Island
licensed hospitals and the Rhode Island Medical
Society, in either electronic or paper format,
written medically acceptable screening criteria and
review procedures which are established and
periodically evaluated and updated with appropriate
consultation with Rhode Island licensed
physicians, hospitals, including practicing physicians,
and other health care providers in the same
specialty as would typically treat the services subject
to the criteria as follows:
(1) Utilization
review agents shall consult with no fewer than five (5) Rhode Island
licensed physicians or other health care
providers. Further, in instances where the screening
criteria and review procedures are applicable to
inpatients and/or outpatients of hospitals, the
medical director of each licensed hospital in
Rhode Island shall also be consulted. Utilization
review agents who utilize screening criteria and
review procedures provided by another entity
may satisfy the requirements of this section if
the utilization review agent demonstrates to the
satisfaction of the director that the entity
furnishing the screening criteria and review procedures
has complied with the requirements of this
section.
(2) Utilization
review agents seeking initial certification shall conduct the consultation
for all screening and review criteria to be
utilized. Utilization review agents who have been
certified for one year or longer shall be
required to conduct the consultation on a periodic basis
for the utilization review agent's highest
volume services subject to utilization review during the
prior year; services subject to the highest
volume of adverse determinations during the prior year;
and for any additional services identified by
the director.
(3) Utilization
review agents shall not include in the consultations as required under
paragraph (1) of this subdivision, any
physicians or other health services providers who have
financial relationships with the utilization
review agent other than financial relationships for
provisions of direct patient care to utilization
review agent enrollees and reasonable compensation
for consultation as required by paragraph (1) of
this subdivision.
(4) All
documentation regarding required consultations, including comments and/or
recommendations provided by the health care
providers involved in the review of the screening
criteria, as well as the utilization review
agent's action plan or comments on any
recommendations, shall be in writing and shall
be furnished to the department on request. The
documentation shall also be provided on request
to any licensed health care provider at a nominal
cost that is sufficient to cover the utilization
review agent's reasonable costs of copying and
mailing.
(5) Utilization
review agents may utilize non-Rhode Island licensed physicians or other
health care providers to provide the
consultation as required under paragraph (1) of this
subdivision, when the utilization review agent
can demonstrate to the satisfaction of the director
that the related services are not currently
provided in Rhode Island or that another substantial
reason requires such approach.
(6) Utilization
review agents whose annualized data reported to the department
demonstrate that the utilization review agent
will review fewer than five hundred (500) such
requests for authorization may request a
variance from the requirements of this section.
23-17.12-10.
External appeals. External appeal requirements. -- (a) In cases
where
the second level of appeal to reverse an adverse
determination is unsuccessful, the review agent
shall provide for an external appeal by an
unrelated and objective appeal agency, selected by the
director. The director shall promulgate rules
and regulations including, but not limited to, criteria
for designation, operation, policy, oversight,
and termination of designation as an external appeal
agency. The external appeal agency shall not be
required to be certified under this chapter for
activities conducted pursuant to its
designation.
(b) The external
appeal shall have the following characteristics:
(1) The external
appeal review and decision shall be based on the medical necessity for
the health care or service and the appropriateness
of service delivery for which authorization has
been denied.
(2) Neutral
physicians, dentists, or other practitioners in the same or similar general
specialty as typically manages the health care
service shall be utilized to make the external appeal
decisions.
(3) Neutral
physicians, dentists, or other practitioners shall be selected from lists:
(i) Mutually
agreed upon by the provider associations, insurers, and the purchasers of
health services; and
(ii) Used during
a twelve (12) month period as the source of names for neutral physician,
dentist, or other practitioner reviewers.
(4) The neutral
physician, dentist, or other practitioner may confer either directly with
the review agent and provider, or with physicians
or dentists appointed to represent them.
(5) Payment for
the appeal fee charged by the neutral physician, dentist, or other
practitioner shall be shared equally between the
two (2) parties to the appeal; provided, however,
that if the decision of the utilization review
agent is overturned, the appealing party shall be
reimbursed by the utilization review agent for
their share of the appeal fee paid under this
subsection.
(6) The decision
of the external appeal agency shall be binding; however, any person
who is aggrieved by a final decision of the
external appeal agency is entitled to judicial review in
a court of competent jurisdiction.
SECTION
2. This act shall take effect upon passage.
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LC03226/SUB
A
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