§ 24-A §2772 — Minimum standards

A utilization review program of the applicant must meet the following minimum standards.
1.
Notification of adverse decisions.
Notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within a time period to be determined by the superintendent through rulemaking and must include the name of the utilization review agent who made the decision.
2.
Reconsideration of determinations.
All licensees shall maintain a procedure by which insureds, patients or providers may seek reconsideration of determinations of the licensee.
3.
Accessibility of representatives.
A representative of the licensee must be accessible by telephone to insureds, patients or providers and the superintendent may adopt standards of accessibility by rule.
3-A.
Medical utilization review criteria.
The licensee must have written medical utilization review criteria to be employed in the review process. The criteria must be available for review as a part of any review conducted pursuant to section 2774, subsection 1 and a copy of the criteria must be provided to the bureau upon request.
4.
Information materials; confidentiality.
A copy of the materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan and an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed must be filed with the bureau.
5.
Penalty for noncompliance with utilization review programs.
A medical utilization review program may not recommend or implement a penalty of more than $500 for failure to provide notification. This subsection does not limit the right of insurers to deny a claim when appropriate prospective or retroactive review concludes that services or treatment rendered were not medically necessary.
6.
Prohibited activities.
A medical utilization review entity shall ensure that an employee does not perform medical utilization review services involving a health care provider or facility in which that employee has a financial interest.

Legislative History

PL 1989, c. 556, §C2 (NEW). RR 1993, c. 2, §15 (COR). PL 1993, c. 602, §§5,6 (AMD). PL 1993, c. 645, §B4 (AMD). PL 1995, c. 332, §§M7,8 (AMD). RR 2015, c. 1, §27 (COR).