A health carrier that requires a request for benefits under the covered person's health plan to be subjected to utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated for the filing of benefit requests, the notification of utilization review and benefit determinations, and the review of adverse determinations in accordance with chapter 58-17I . The program document shall describe the following:
(1)Procedures to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services;
(2)Data sources and clinical review criteria used in decision-making;
(3)Mechanisms to ensure consistent application of review criteria and compatible decisions;
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A health carrier that requires a request for benefits under the covered person's health plan to be subjected to utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated for the filing of benefit requests, the notification of utilization review and benefit determinations, and the review of adverse determinations in accordance with chapter 58-17I . The program document shall describe the following: (1) Procedures to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services; (2) Data sources and clinical review criteria used in decision-making; (3) Mechanisms to ensure consistent application of review criteria and compatible decisions; (4) Data collection processes and analytical methods used in assessing utilization of health care services; (5) Provisions for assuring confidentiality of clinical and proprietary information; (6) The organizational structure that periodically assesses utilization review activities and reports to the health carrier's governing body; and (7) The staff position functionally responsible for day-to-day program management. A health carrier shall prepare an annual summary report in the format specified of its utilization review program activities and file the report, if requested, with the director and the secretary. A health carrier shall maintain records for a minimum of six years of all benefit requests and claims and notices associated with utilization review and benefit determinations made in accordance with §§ 58-17H-27 to 58-17H-32 , inclusive, and §§ 58-17H-40 to 58-17H-48 , inclusive. The health carrier shall make the records available for examination by covered persons and the director upon request. Commission Note: