§ 4905 — Required and prohibited practices

§ 4905. Required and prohibited practices. (a) Each utilization review\nagent shall have written procedures for assuring that patient-specific\ninformation obtained during the process of utilization review will be:\n (1) kept confidential in accordance with applicable state and federal\nlaws; and\n (2) shared only with the insured, the insured's designee, the\ninsured's health care provider and those who are authorized by law to\nreceive such information.\n (b) Summary data shall not be considered confidential if it does not\nprovide information to allow identification of individual patients.\n (c) Any health care professional who makes determinations regarding\nthe medical necessity of health care services during the course of\nutilization review shall be appropriately licensed, registered or\ncertified.\n (d) A utilization review agent shall not, with respect to utilization\nreview activities, permit or provide compensation or anything of value\nto its employees, agents, or contractors based on:\n (1) either a percentage of the amount by which a claim is reduced for\npayment or the number of claims or the cost of services for which the\nperson has denied authorization or payment; or\n (2) any other method that encourages the rendering of an adverse\ndetermination.\n (e) If a health care service has been specifically preauthorized or\napproved for an insured by a utilization review agent, a utilization\nreview agent shall not pursuant to retrospective review revise or modify\nthe specific standards, criteria or procedures used for the utilization\nreview for procedures, treatment and services delivered to the insured,\nduring the same course of treatment.\n (f) Utilization review shall not be conducted more frequently than is\nreasonably required to assess whether the health care services under\nreview are medically necessary.\n (g) When making prospective, concurrent and retrospective\ndeterminations, utilization review agents shall collect only such\ninformation as is necessary to make such determination and shall not\nroutinely require health care providers to numerically code diagnoses or\nprocedures to be considered for certification or routinely request\ncopies of medical records of all patients reviewed. During prospective\nor concurrent review, copies of medical records shall only be required\nwhen necessary to verify that the health care services subject to such\nreview are medically necessary. In such cases, only the necessary or\nrelevant sections of the medical record shall be required. A utilization\nreview agent may request copies of partial or complete medical records\nretrospectively.\n (h) In no event shall information be obtained from the health care\nproviders for the use of the utilization review agent by persons other\nthan health care professionals, medical record technologists or\nadministrative personnel who have received appropriate training.\n (i) The utilization review agent shall not undertake utilization\nreview at the site of the provision of health care services unless the\nutilization review agent:\n (1) Identifies himself or herself by name and the name of his or her\norganization, including displaying photographic identification which\nincludes the name of the utilization review agent and clearly identifies\nthe individual as representative of the utilization review agent;\n (2) Whenever possible, schedules review at least one business day in\nadvance with the appropriate health care provider;\n (3) If requested by a health care provider, assures that the on-site\nreview staff register with the appropriate contact person, if available,\nprior to requesting any clinical information or assistance from the\nhealth care provider; and\n (4) Obtains consent from the insured or the insured's designee before\ninterviewing the patient's family, or observing any health care service\nbeing provided to the insured.\n (5) This subsection shall not apply to health care professionals\nengaged in providing care or case management or making on-site discharge\ndecisions.\n (j) A utilization review agent shall not base an adverse determination\non a refusal to consent to observing any health care service.\n (k) A utilization review agent shall not base an adverse determination\non lack of reasonable access to a health care provider's medical or\ntreatment records unless the utilization review agent has provided\nreasonable notice to the insured, the insured's designee or the\ninsured's health care provider, in which case the insured must be\nnotified, and has complied with all provisions of subsection (i) of this\nsection.\n (l) Neither the utilization review agent nor the entity for which the\nagent provides utilization review shall take any action with respect to\na patient or a health care provider that is intended to penalize such\ninsured, the insured's designee, or the insured's health care provider\nfor, or to discourage such insured, the insured's designee, or the\ninsured's health care provider from undertaking an appeal, dispute\nresolution or judicial review of an adverse determination.\n (m) In no event shall an insured, an insured's designee, an insured's\nhealth care provider, any other health care provider, or any other\nperson or entity be required to inform or contact the utilization review\nagent prior to the provision of emergency care, including emergency\ntreatment or emergency admission.\n (n) No contract or agreement between a utilization review agent and a\nhealth care provider shall contain any clause purporting to transfer to\nthe health care provider by indemnification or otherwise any liability\nrelating to activities, actions or omissions of the utilization review\nagent as opposed to the health care provider.\n (o) A health care professional providing health care services to an\ninsured shall be prohibited from serving as the clinical peer reviewer\nfor such insured in connection with the health care services being\nprovided to the insured.\n