20-2502. Utilization review activities;
exemptions
A. A utilization review agent shall not conduct utilization review in this state
unless the utilization review agent meets or is exempt from the provisions of this
article.
B. A person is exempt from the provisions of this article if the person:
1. Is accredited by the utilization review accreditation commission, the national
committee for quality assurance or any other nationally recognized accreditation process
recognized by the director.
2. Conducts internal utilization review for hospitals, home health agencies,
clinics, private offices or other health facilities or entities if the review does not
result in the approval or denial of payment for hospital or medical services.
3. Conducts utilization review activities exclusively for work related injuries and
illnesses covered under the workers' compensation laws in title 23.
4. Conducts utilization review activities exclusively for a self-funded or
self-insured employee benefit plan if the regulation of that plan is preempted by section
514(b) of the employee retirement income security act of 1974, 29 United States Code
section 1144(b).
C. A utilization review agent shall conduct utilization review in accordance with
the agent's utilization review plan that is on file with the department pursuant to
section 20-2505 and in accordance with section 20-2532.
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