§ 27-18.9-13. Denial, suspension, or revocation of certificate — Penalties.
Adopted pursuant to this chapter;
(a) The office may deny a certificate or certification upon review of the application
if, upon review of the application, it finds that the applicant proposing to conduct
utilization review does not meet the standards required by this chapter or by any
regulations promulgated pursuant to this chapter.
(b) The office may revoke or suspend a certificate or certification and/or impose monetary
penalties not less than one hundred dollars ($100) and not to exceed fifty thousand
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§ 27-18.9-13. Denial, suspension, or revocation of certificate — Penalties.
Adopted pursuant to this chapter;
(a) The office may deny a certificate or certification upon review of the application
if, upon review of the application, it finds that the applicant proposing to conduct
utilization review does not meet the standards required by this chapter or by any
regulations promulgated pursuant to this chapter.
(b) The office may revoke or suspend a certificate or certification and/or impose monetary
penalties not less than one hundred dollars ($100) and not to exceed fifty thousand
dollars ($50,000) per violation and/or impose an order requiring a monetary restitution
or disgorgement payment in an amount determined by the commissioner to reasonably
reflect the amount of damages caused or monies improperly obtained in any case in
which:
(1) The healthcare entity and/or review agent fails to comply with the requirements of
this chapter or of regulations;
(2) The review agent/network plan and/or healthcare entity and/or review agent fails to
comply with the criteria used by it in its application for a certificate or certification;
or
(3) The healthcare entity and/or review agent refuses to permit or fails to reasonably
cooperate with an examination by the commissioner to determine compliance with the
requirements of this chapter and regulations promulgated pursuant to the authority
granted to the commissioner in this chapter. These determinations may involve consideration
of any written grievances filed with the office against the healthcare entity and/or
review agent by patients or providers.
(c) Any applicant or certificate or certification holder aggrieved by an order or a decision
of the commissioner made under this chapter without a hearing may, within thirty (30)
days after notice of the order or decision, make a written request to the office for
a hearing on the order or decision pursuant to § 42-35-15.
(d) The procedure governing hearings authorized by this section shall be in accordance
with §§ 42-35-9 through 42-35-13 as stipulated in § 42-35-14(a). A full and complete record shall be kept of all proceedings, and all testimony shall
be recorded but need not be transcribed unless the decision is appealed pursuant to
§ 42-35-15. A copy or copies of the transcript may be obtained by any interested party upon
payment of the cost of preparing the copy or copies. Witnesses may be subpoenaed by
either party.