§ 27-18.9-4. Application requirements.
An application for review agent certification or recertification shall include, but
is not limited to, documentation to evidence the following:
(a) Administrative and non-administrative benefit determinations.
(1) That the healthcare entity or its review agent provide beneficiaries and providers
with a summary of its benefit determination review programs and adverse benefit determination
criteria in a manner acceptable to the commissioner that includes a summary of the
standards, procedures, and methods to be used in evaluating proposed, concurrent,
or delivered healthcare services;
(2) The circumstances, if any, under which review agent may be delegated to and evidence
that the delegated review agent is a certified review agent pursuant to the requirements
of this chapter;
(3) A complaint resolution process acceptable to the commissioner, whereby beneficiaries
or other healthcare providers may seek resolution of complaints and other matters
of which the review agent has received notice;
(4) Policies and procedures to ensure that all applicable state and federal laws to protect
the confidentiality of individual medical records are followed;
(5) Requirements that no employee of, or other individual rendering an adverse benefit
determination or appeal decision may receive any financial or other incentives based
upon the number of denials of certification made by that employee or individual;
(6) Evidence that the review agent has not entered into a compensation agreement or contract
with its employees or agents whereby the compensation of its employees or its agents
is based, directly or indirectly, upon a reduction of services or the charges for
those services, the reduction of length of stay, or use of alternative treatment settings;
(7) An adverse benefit determination and internal appeals process consistent with this chapter and acceptable to the office, whereby beneficiaries, their physicians, or other healthcare
service providers may seek prompt reconsideration or appeal of adverse benefit determinations
by the review agent according to all state and federal requirements; and
(8) That the healthcare entity or its review agent has a mechanism to provide the beneficiary
or claimant with a description of its claims procedures and any procedures for obtaining
approvals as a prerequisite for obtaining a benefit or for obtaining coverage for
such benefit. This description should, at a minimum, be placed in the summary of benefits
document and available on the review agent's or the relevant healthcare entity's website
and upon request from the claimant, the claimant's authorized representative, and
ordering providers.
(b) Non-administrative benefit determinations general requirements.
(1) Type and qualifications of personnel (employed or under contract) authorized to perform
utilization review, including a requirement that only a provider with the same license
status as the ordering professional provider or a licensed physician or dentist is
permitted to make a prospective or concurrent utilization review adverse benefit determination;
(2) Requirement that a representative of the utilization review agent is reasonably accessible
to beneficiaries and providers at least five (5) days a week during normal business
hours in Rhode Island and during the hours of the agency's operations when conducting
utilization review;
(3) Policies and procedures regarding the notification and conduct of patient interviews
by the utilization review agent to include a process and assurances that such interviews
do not disrupt care; and
(4) Requirement that the utilization review agent shall not impede the provision of healthcare
services for treatment and/or hospitalization or other use of a provider's services
or facilities for any beneficiary.