§ 27-18.9-3. Certification and recertification of review agents.
(a) A review agent shall not conduct benefit determination reviews in the state unless
the office has granted the review agent a certificate.
(b) Individuals shall not be required to hold a separate review agent certification under
this chapter when acting as either an employee of, an affiliate of, a contractor for,
or otherwise acting on behalf of a certified review agent.
(c) The commissioner shall establish a process for the certification of review agents
meeting the requirements of certification.
(d) The commissioner shall establish procedures for the periodic review and recertification
of review agents at least every three (3) years.
(e) A certificate issued under this chapter is not transferable, and the transfer of fifty
percent (50%) or more of the ownership of a review agent shall be deemed a transfer.
(f) The office shall issue a review agent certificate to an applicant who or that has
met the minimum standards defined in this chapter, and regulations promulgated in
accordance with it, including the payment of any fees as required, and other applicable
regulations of the office.
(g) In the event of any systemic changes in the review agent certification information
on file with the office, the review agent shall submit notice and explanation of this
change for approval by the commissioner at least thirty (30) calendar days prior to
implementation of any such change.
(h) The total cost of obtaining and maintaining a review agent certification under this
title and in compliance with the requirements of the applicable rules and regulations
shall be borne by the applicant and shall include one hundred fifty percent (150%)
of the total salaries paid to the personnel engaged in certifications and ensuring
compliance with the requirements herein and applicable rules and regulations. These
monies shall be paid to the commissioner to and for the use of the office and shall
be in addition to any taxes and fees otherwise payable to the state.
(i) Notwithstanding any other provision of law, the review agent, the office, and all
other parties privy to information that is the subject of this chapter shall comply
with all state and federal confidentiality laws, including, but not limited to, chapter 37.3 of title 5 (confidentiality of health care communications and information act) and specifically
§ 5-37.3-4(c), which requires limitation on the distribution of information that is the subject
of this chapter on a "need to knowâ€� basis, and § 40.1-5-26.
(j) The office may, in response to a complaint or inquiry, review a benefit determination
or appeal and may request information of the review agent, provider, or beneficiary
regarding the status, outcome, or rationale regarding any decision. The review agent
shall promptly respond to any such requests by the office.
(k) The office shall adopt regulations necessary to implement the provisions of this chapter.