TITLE 27
Insurance

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

SECTION 27-18.9-3


§ 27-18.9-3. Certification and recertification of review agents. [Effective January 1, 2018.].

(a) A review agent shall not conduct benefit determination reviews in the state unless the office has granted the review agent a certificate.

(b) Individuals shall not be required to hold a separate review agent 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 commissioner shall establish a process for the certification of review agents meeting the requirements of certification.

(d) The commissioner shall establish procedures for the periodic review and recertification of review agents at least every three (3) years.

(e) 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) The office shall issue a review agent certificate to an applicant who or that has met the minimum standards defined in this chapter, and regulations promulgated in accordance with it, including the payment of any fees as required, and other applicable regulations of the office.

(g) In the event of any systemic changes in the review agent certification information on file with the office, the review agent shall submit notice and explanation of this change for approval by the commissioner at least thirty (30) calendar days prior to implementation of any such change.

(h) The total cost of obtaining and maintaining a review agent certification under this title and in compliance with the requirements of the applicable rules and regulations shall be borne by the applicant and shall include one hundred fifty percent (150%) of the total salaries paid to the personnel engaged in certifications and ensuring compliance with the requirements herein and applicable rules and regulations. These monies shall be paid to the commissioner to and for the use of the office and shall be in addition to any taxes and fees otherwise payable to the state.

(i) Notwithstanding any other provision of law, the review agent, the office, and all other parties privy to information that 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 § 5-37.3-4(c), which requires limitation on the distribution of information that is the subject of this chapter on a "need to know" basis, and § 40.1-5-26.

(j) The office may, in response to a complaint or inquiry, review a benefit determination or appeal and may request information of the review agent, provider, or beneficiary regarding the status, outcome, or rationale regarding any decision. The review agent shall promptly respond to any such requests by the office.

(k) The office shall adopt regulations necessary to implement the provisions of this chapter.

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