Chapter
355
2006 -- S 2753 SUBSTITUTE A AS AMENDED
Enacted 07/07/06
A N A
C T
RELATING TO HEALTH
CARE SERVICES - UTILIZATION REVIEW ACT
Introduced By: Senator
Elizabeth H. Roberts
Date Introduced: February
14, 2006
It is enacted
by the General Assembly as follows:
SECTION
1. Sections 23-17.12-2, 23-17.12-3, 23-17.12-4, 23-17.12-5, 23-17.12-8 and
23-17.12-9
of the General Laws in Chapter 23-17.12 entitled "Health Care Services -
Utilization
Review
Act" are hereby amended to read as follows:
23-17.12-2.
Definitions. -- As used in this chapter, the following terms are
defined as
follows:
(1) "Adverse determination" means any a utilization review
decision by a review agent
not to certify
authorize a health care service. A decision by a review agent to certify
authorize a
health
care service in an alternative setting, a modified extension of stay, or an
alternative
treatment
shall not constitute an adverse determination if the review agent and provider
are in
agreement
regarding the decision. Adverse determinations include decisions not to certify
authorize
formulary and nonformulary
medication.
(2)
"Appeal" means a subsequent review of an adverse determination upon
request by a
patient
or provider to reconsider all or part of the original decision.
(3)
"Authorization" means the review agent's utilization review,
performed according to
subsection
23-17.12-2(20), concluded that the allocation of health care services of a
provider,
given
or proposed to be given to a patient was approved or authorized.
(4)
"Benefit determination" means a decision of the enrollee's
entitlement to payment for
covered
health care services as defined in an agreement with the payor or its delegate.
(2) (5) "Certificate" means a certificate of
registration granted by the director to a review
agent.
(6)
"Complaint" means a written expression of dissatisfaction by a
patient, or provider.
The
appeal of an adverse determination is not considered a complaint.
(7)
"Concurrent assessment" means an assessment of the medical necessity
and/or
appropriateness
of health care services conducted during a patient's hospital stay or course of
treatment.
If the medical problem is ongoing, this assessment may include the review of
services
after
they have been rendered and billed. This review does not mean the elective
requests for
clarification
of coverage or claims review or a provider's internal quality assurance program
except
if it is associated with a health care financing mechanism.
(3) (8) "Department" means the department of health.
(4) (9) "Director" means the director of the department
of health.
(5) (10) "Emergent health care services" has the same
meaning as that meaning
contained
in the rules and regulations promulgated pursuant to chapter 12.3 of title 42
as may be
amended
from time to time and includes those resources provided in the event of the
sudden onset
of a
medical, mental health, or substance abuse or other health care condition
manifesting itself
by acute
symptoms of a severity (e.g. severe pain) where the absence of immediate
medical
attention
could reasonably be expected to result in placing the patient's health in
serious jeopardy,
serious
impairment to bodily or mental functions, or serious dysfunction of any body
organ or
part.
(6) (11) "Patient" means an enrollee or participant in
all hospital or medical plans
seeking
health care services and treatment from a provider.
(12)
"Payor" means a health insurer, self-insured plan, nonprofit health
service plan,
health
insurance service organization, preferred provider organization, health
maintenance
organization
or other entity authorized to offer health insurance policies or contracts or pay
for
the
delivery of health care services or treatment in this state.
(7) (13) "Practitioner" means any person licensed to
provide or otherwise lawfully
providing
health care services, including, but not limited to, a physician, dentist,
nurse,
optometrist,
podiatrist, physical therapist, clinical social worker, or psychologist.
(14)
"Prospective assessment" means an assessment of the medical necessity
and/or
appropriateness
of health care services prior to services being rendered.
(8) (15) "Provider" means any health care facility, as
defined in section 23-17-2
including
any mental health and/or substance abuse treatment facility, physician, or
other licensed
practitioners
identified to the review agent as having primary responsibility for the care,
treatment,
and services rendered to a patient.
(16)
"Retrospective assessment" means an assessment of the medical
necessity and/or
appropriateness
of health care services that have been rendered. This shall not include reviews
conducted
when the review agency has been obtaining ongoing information.
(9) (17) "Review agent" means a person or entity or
insurer performing utilization
review
that is either employed by, affiliated with, under contract with, or acting on
behalf of:
(i) A business entity doing business in this state;
(ii) A party that provides or administers health care benefits to citizens of
this state,
including
a health insurer, self-insured plan, non-profit health service plan, health
insurance
service
organization, preferred provider organization or health maintenance
organization
authorized
to offer health insurance policies or contracts or pay for the delivery of
health care
services
or treatment in this state; or
(iii) A provider.
(18)
"Same or similar specialty" means a practitioner who has the
appropriate training
and
experience that is the same or similar as the attending provider in addition to
experience in
treating
the same problems to include any potential complications as those under review.
(10) (19) "Urgent health care services" has the same
meaning as that meaning contained
in the
rules and regulations promulgated pursuant to chapter 12.3 of title 42 as may
be amended
from time
to time and includes those resources necessary to treat a symptomatic medical,
mental
health,
or substance abuse or other health care condition requiring treatment within a
twenty-four
(24)
hour period of the onset of such a condition in order that the patient's health
status not
decline
as a consequence. This does not include those conditions considered to be
emergent
health
care services as defined in subdivision (5) (10).
(11) (20) "Utilization review" means the prospective,
concurrent, or retrospective
assessment
of the necessity and/or appropriateness of the allocation of health care
services of a
provider,
given or proposed to be given to a patient or group of patients.
Utilization review does
not
include:
(i) Elective requests for the clarification of coverage; or
(ii)
Benefit determination; or
(ii)
(iii) Claims review that does not include the assessment of the medical
necessity and
appropriateness;
or
(iii) (iv) A provider's internal quality assurance program except
if it is associated with a
health
care financing mechanism; or
(iv) (v) The therapeutic interchange of drugs or devices by a
pharmacy operating as part
of a
licensed inpatient health care facility; or
(v) (vi) The assessment by a pharmacist licensed pursuant to the
provisions of chapter 19
of title
5 and practicing in a pharmacy operating as part of a license licensed
inpatient health care
facility
in the interpretation, evaluation and implementation of medical orders,
including
assessments
and/or comparisons involving formularies and medical orders.
(12) (21) "Utilization review plan" means a description
of the standards governing
utilization
review activities performed by a private review agent.
(13) (22) "Health care services" means and includes an
admission, diagnostic procedure,
therapeutic
procedure, treatment, extension of stay, the ordering and/or filling of
formulary or
nonformulary
medications, and any other services, activities, or supplies that are covered
by the
patient's
benefit plan.
(14) (23) "Therapeutic interchange" means the
interchange or substitution of a drug with
a
dissimilar chemical structure within the same therapeutic or pharmacological
class that can be
expected
to have similar outcomes and similar adverse reaction profiles when given in
equivalent
doses,
in accordance with protocols approved by the president of the medical staff or
medical
director
and the director of pharmacy.
23-17.12-3.
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) 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.
(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.
(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.
(e) After consultation with the payers payors and providers of
health care, the
department
shall adopt regulations necessary to implement the provisions of this chapter.
(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.
(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 process. -- (a) An applicant requesting certification or
recertification
shall:
(1) Submit an application provided by the director; and
(2) Pay the application fee established by the director through regulation and
section 23-
17.12-3(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.
(e) In conjunction with the application, the review agent shall submit
information that
the
director requires including:
(1) 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);
(2) The policies and procedures to ensure that all applicable state and federal
laws to
protect
the confidentiality of individual medical records are followed;
(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;
(4) A copy of the materials designed to inform applicable patients and
providers of the
requirements
of the utilization review plan;
(5) A list of the third party payers payors 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
(6) Evidence of liability insurance or of assets sufficient to cover potential
liability.
(f) The information provided must demonstrate that the review agent will comply
with
the
regulations adopted by the director under this chapter.
23-17.12-5.
General application requirements. -- 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 delegated to perform utilization review pursuant to all of
the requirements of this
chapter;
(c) A complaint resolution process, consistent with section 23-17.12-9
subsection 23-
17.12-2(6) 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
licensure 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 appeals process as
required by this
chapter. 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
determinations by the review agent.
23-17.12-8.
Waiver of requirements. -- (a) Except for utilization review agencies
performing
utilization review activities performed
to determine the necessity and/or
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.
(c)
The limitation in subsection 23-17.12-8(b) notwithstanding, the department may
waive
or exempt all or part of the requirements of this chapter by mutual written
agreement with
a
state department or agency when such waiver or exemption is determined to be
necessary and
appropriate
to the administration of a health care related program. The department shall
promulgate
such regulations as deemed appropriate to implement this provision.
23-17.12-9.
Review agency requirement for adverse determination and internal
appeals.
-- (a) The decision adverse
determination and appeals process of the review agent shall
conform
to the following:
(1) Notification of a prospective adverse 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. as follows:
(i)
Within fifteen (15) business days of receipt of all the information necessary
to
complete
a review of non-urgent and/or non-emergent services;
(ii)
Within seventy-two (72) hours of receipt of all the information necessary to
complete
a
review of urgent and/or emergent services; and
(iii)
Prior to the expected date of service.
(2) Notification of a concurrent adverse 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 as
follows: consistent with time frames to be established in regulations
promulgated by the
department.
(i)
To the provider(s) prior to the end of the current certified period; and
(ii)
To the patient within one business day of making the adverse determination.
(3) Notification of a retrospective adverse 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 authorization
for
health
care services provided to a covered person when prior approval an
authorization has been
obtained
for that service 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.
(5) Any notice of a an adverse determination not to certify a
health care service shall be
made,
documented, and signed and shall be mailed or otherwise communicated, and shall include:
(i) The principal reasons for the adverse determination, and to
include explicit
documentation
of the criteria not met and/or the clinical rationale utilized by the agency's
clinical
reviewer
in making the adverse determination. The criteria shall be in accordance with
the agency
criteria
noted in subsection 23-17.12-9(d) and shall be made available within the first
level appeal
timeframe
if requested unless otherwise provided as part of the adverse determination
notification
process;
(ii) The procedures to initiate an appeal of the adverse determination,
including or the
name and
telephone number of the person to contract with regard to an appeal. ;
(iii)
The necessary contact information to complete the two-way direct communication
defined
in subdivision 23-17.12-9 (a)(7); and
(iv)
The information noted in subdivision 23-27.12-9(a)(5)(i)(ii)(iii) for all
verbal
notifications
followed by written notification to the patient and provider(s).
(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 A level one appeal decision of an
adverse
determination that care rendered or to be rendered is medically
inappropriate shall not 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.
, with the
exception
of the following:
(i)
When the attending provider is not reasonably available;
(ii)
When the attending provider chooses not to speak with agency staff;
(iii)
When the attending provider has negotiated an agreement with the review agent
for
alternative
care; and/or
(iv)
When the attending provider requests a peer to peer communication prior to the
adverse
determination, the review agency shall then comply with subdivision
23-17.12-9(c)(1) in
responding
to such a request. Such requests shall be on the case specific basis unless
otherwise
arranged
for in advance by the provider.
(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. This does not prohibit appropriately qualified review
agency staff
from
engaging in discussions with the attending provider, the attending provider's
designee or
appropriate
health care facility and office personnel regarding alternative service and
treatment
options.
Such a discussion shall not constitute an adverse determination provided though
that any
change
to the provider's original order and/or any decision for an alternative level
of care must be
made
and/or appropriately consented to by the attending provider or the provider's
designee
responsible
for treating the patient.
(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) (9) The requirement that, upon written request made by or on
behalf of a patient,
any adverse
determination and/or appeal 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:
(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 authorize 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.
(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
business days if verbal notice is given within fifteen (15) working
business days
after
receiving the required documentation on the appeal.
(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.
(4)
All first level appeals of determinations not to authorize 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.
(4)(5) In cases where an initial appeal to reverse an adverse
determination is
unsuccessful,
the review agent shall assure that All
second level appeal decisions shall be made,
signed,
and documented by 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.
(5)(6) The review agent shall maintain records of written appeals
and their resolution,
and
shall provide reports as requested by the department.
(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:
(1) The review agent must assure that the licensed practitioner or licensed
physician is
reasonably
available to review the case as required under subsection 23-17.12-3(e).
subdivision
23-17.12-9(a)(7)
and shall conform to the following:
(i)
Each agency peer reviewer shall have access to and review all necessary
information
as
requested by the agency and/or submitted by the provider(s) and/or patients;
(ii)
Each agency shall provide accurate peer review contact information to the
provider at
the
time of service, if requested, and/or prior to such service, if requested. This
contact
information
must provide a mechanism for direct communication with the agency's peer
reviewer;
(iii)
Agency peer reviewers shall respond to the provider's request for a two-way
direct
communication
defined in subdivision 23-17.12-9(a)(7)(iv) as follows:
(a)
For a prospective review of non-urgent and non-emergent health care services, a
response
within one (1) business day of the request for a peer discussion;
(b)
For concurrent and prospective reviews of urgent and emergent health care
services, a
response
within a reasonable period of time of the request for a peer discussion; and
(c)
For retrospective reviews, prior to the first level appeal decision.
(iv)
The review agency will have met the requirements of a two-way direct
communication,
when requested and/or as required prior to the first level of appeal, when it
has
made
two (2) reasonable attempts to contact the attending provider directly.
(v)
Repeated violations of this section shall be deemed to be substantial
violations
pursuant
to section 23-17.12-14 and shall be cause for the imposition of penalties under
that
section.
(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.
(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.
(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).
(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 upon
request, as
determined
appropriate by the director, to by
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.
SECTION
2. This act shall take effect on January 1, 2007.
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LC01790/SUB A
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