§ 27-18.9-5. Administrative and non-administrative benefit determination procedural requirements.
(a) Procedural failure by claimant.
(1) In the event of the failure of the claimant or an authorized representative to follow
the healthcare entities claims procedures for a pre-service claim, the healthcare
entity or its review agent must:
(i) Notify the claimant or the authorized representative, as appropriate, of this failure
as soon as possible and no later than five (5) calendar days following the failure
and this notification must also inform the claimant of the proper procedures to file
a pre-service claim; and
(ii) Notwithstanding the above, if the pre-service claim relates to urgent or emergent
healthcare services, the healthcare entity or its review agent must notify and inform
the claimant or the authorized representative, as appropriate, of the failure and
proper procedures within twenty-four (24) hours following the failure. Notification
may be oral, unless written notification is requested by the claimant or authorized
representative.
(2) The claimant must have stated name, specific medical condition or symptom, and specific
treatment, service, or product for which approval is requested and submitted to proper
claim processing unit.
(b) Utilization review agent procedural requirements.
(1) All initial, prospective, and concurrent non-administrative adverse benefit determinations
of a healthcare service that had been ordered by a physician, dentist, or other practitioner
shall be made, documented, and signed by a licensed practitioner with the same licensure
status as the ordering provider;
(2) Utilization review agents are not prohibited from allowing appropriately qualified
review agency staff to engage in discussions with the attending provider, the attending
provider's designee, or appropriate healthcare facility and office personnel regarding
alternative service and/or treatment options. Such a discussion shall not constitute
an adverse benefit determination; provided, however, that any change to the attending
provider's original order and/or any decision for an alternative level of care must
be made and/or appropriately consented to by the attending provider or the provider's
designee responsible for treating the beneficiary and must be documented by the review
agent; and
(3) A utilization review agent shall not retrospectively deny authorization for healthcare
services provided to a covered person when an authorization has been obtained for
that service from the review agent unless the approval was based upon inaccurate information
material to the review or the healthcare services were not provided consistent with
the provider's submitted plan of care and/or any restrictions included in the prior
approval granted by the review agent.