§ 10-4-115 — Private utilization review

(1) As used in this section, unless the
context otherwise requires:

(a) Private utilization review organization means an entity, other than a
hospital or public reviewer following federal guidelines, which conducts utilization
review.

(b) Utilization review means an evaluation of the necessity,
appropriateness, and efficiency of the use of health-care services, procedures, and
facilities, but does not include any independent medical examination provided for in
any policy of insurance.

(2) An insurance carrier regulated pursuant to the provisions of this article
may contract with any private utilization review organization and receive from that
private utilization review organization a utilization review opinion. If the insurance
carrier relies on the opinion of the private utilization review organization resulting in
a decision to not pay benefits that an appropriate fact finder later determines were
due and owing, then the insurance carrier shall be responsible to pay the past due
benefits in addition to interest and costs. Nothing in this subsection (2) shall be
construed to affect or limit the commissioner's power to regulate under the
provisions of section 10-3-1104 (1)(h), nor shall anything in this subsection (2) limit or
affect the insured's remedies under part 6 of this article, or any common law
remedy.

Legislative History

Source: L. 93: Entire section added, p. 493, � 1, effective April 26. L. 2003: (2) amended, p. 1571, � 6, effective July 1.