Title 27
Insurance

Chapter 18.9
Benefit Determination and Utilization Review Act

§ 27-18.9-4. Application requirements.

An application for review agent certification or recertification shall include, but is not limited to, documentation to evidence the following:

(a) Administrative and non-administrative benefit determinations:

(1) That the healthcare entity or its review agent provide beneficiaries and providers with a summary of its benefit determination review programs and adverse benefit determination criteria in a manner acceptable to the commissioner that includes a summary of the standards, procedures, and methods to be used in evaluating proposed, concurrent, or delivered healthcare services;

(2) The circumstances, if any, under which review agent may be delegated to and evidence that the delegated review agent is a certified review agent pursuant to the requirements of this chapter;

(3) A complaint resolution process acceptable to the commissioner, whereby beneficiaries or other healthcare providers may seek resolution of complaints and other matters of which the review agent has received notice;

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

(5) Requirements that no employee of, or other individual rendering an adverse benefit determination or appeal decision may receive any financial or other incentives based upon the number of denials of certification made by that employee or individual;

(6) 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, directly or indirectly, upon a reduction of services or the charges for those services, the reduction of length of stay, or use of alternative treatment settings;

(7) An adverse benefit determination and internal appeals process consistent with chapter 18.9 of title 27 and acceptable to the office, whereby beneficiaries, their physicians, or other healthcare service providers may seek prompt reconsideration or appeal of adverse benefit determinations by the review agent according to all state and federal requirements; and

(8) That the healthcare entity or its review agent has a mechanism to provide the beneficiary or claimant with a description of its claims procedures and any procedures for obtaining approvals as a prerequisite for obtaining a benefit or for obtaining coverage for such benefit. This description should, at a minimum, be placed in the summary of benefits document and available on the review agent’s or the relevant healthcare entity’s website and upon request from the claimant, his/her authorized representative and ordering providers.

(b) Non-administrative benefit determinations general requirements:

(1) Type and qualifications of personnel (employed or under contract) authorized to perform utilization review, including a requirement that only a provider with the same license status as the ordering professional provider or a licensed physician or dentist is permitted to make a prospective or concurrent utilization review adverse benefit determination;

(2) Requirement that a representative of the utilization review agent is reasonably accessible to beneficiaries and providers at least five (5) days a week during normal business hours in Rhode Island and during the hours of the agency’s operations when conducting utilization review;

(3) Policies and procedures regarding the notification and conduct of patient interviews by the utilization review agent to include a process and assurances that such interviews do not disrupt care; and

(4) Requirement that the utilization review agent shall not impede the provision of healthcare services for treatment and/or hospitalization or other use of a provider’s services or facilities for any beneficiary.