TITLE 27
Insurance

CHAPTER 27-18.9
Benefit Determination and Utilization Review Act [Effective January 1, 2018.]

SECTION 27-18.9-13


§ 27-18.9-13. Denial, suspension, or revocation of certificate – Penalties. [Effective January 1, 2018.].

Adopted pursuant to this chapter;

(a) The office may deny a certificate or certification 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 office may revoke or suspend a certificate or certification and/or impose monetary penalties not less than one hundred dollars ($100) and not to exceed fifty thousand dollars ($50,000) per violation and/or impose an order requiring a monetary restitution or disgorgement payment in an amount determined by the commissioner to reasonably reflect the amount of damages caused or monies improperly obtained in any case in which:

(1) The health care entity and/or review agent fails to comply with the requirements of this chapter or of regulations;

(2) The review agent/network plan and/or health care entity and/or review agent fails to comply with the criteria used by it in its application for a certificate or certification; or

(3) The health care entity and/or review agent refuses to permit or fails to reasonably cooperate with an examination by the commissioner to determine compliance with the requirements of this chapter and regulations promulgated pursuant to the authority granted to the commissioner in this chapter. These determinations may involve consideration of any written grievances filed with the office against the health care entity and/or review agent by patients or providers.

(c) Any applicant or certificate or certification holder aggrieved by an order or a decision of the commissioner 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 office for a hearing on the order or decision pursuant to § 42-35-15.

(d) The procedure governing hearings authorized by this section shall be in accordance with §§ 42-35-9 through 42-35-13 as stipulated in § 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 § 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.

History of Section.
(P.L. 2017, ch. 302, art. 5, § 5.)