TITLE 23
Health and Safety

CHAPTER 23-17.12
Health Care Services – Utilization Review Act

SECTION 23-17.12-5


§ 23-17.12-5 General application requirements.

An application for certification or recertification shall be accompanied by documentation to evidence 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 delegated to perform utilization review pursuant to all of the requirements of this chapter;

(3) A complaint resolution process consistent with subsection 23-17.12-2(6) and acceptable to the department, whereby patients, their physicians, or other health care providers may seek resolution of complaints and other matters of which the review agent has received written notice;

(4) 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 license 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 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;

(6) The policies and procedures to ensure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed;

(7) The policies and procedures regarding the notification and conduct of patient interviews by the review agent;

(8) 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;

(9) 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;

(10) 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

(11) An adverse determination and internal appeals process consistent with § 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.

History of Section.
(P.L. 1992, ch. 398, § 1; P.L. 1999, ch. 222, § 1; P.L. 1999, ch. 512, § 1; P.L. 2005, ch. 184, § 1; P.L. 2005, ch. 238, § 1; P.L. 2006, ch. 221, § 1; P.L. 2006, ch. 355, § 1; P.L. 2008, ch. 475, § 50.)