20-2505. Application for certification
A utilization review agent applying for a certificate shall submit the following
information to the department:
1. A signed and notarized application on a form prescribed by the director.
2. A utilization review plan that includes a summary description of review
guidelines, protocols and procedures, standards and criteria to be used in evaluating
inpatient hospital care, inpatient medical care, outpatient surgical care and any
medical, surgical and health care services that may be covered by a health care insurer
and the provisions by which patients, providers or hospitals may seek reconsideration or
appeal of decisions made by the utilization review agent.
3. The professional qualifications of the personnel either employed or under
contract to perform the utilization review. Personnel conducting utilization review
shall have current licenses that are in good standing and without restrictions from a
state health care professional licensing agency in the United States and may be a member
of a profession that practices inpatient hospital or outpatient surgical care.
4. A description of the policies and procedures that ensure that a representative
of the utilization review agent is available to receive and send the notice and
acknowledgments prescribed in article 2 of this chapter and is reasonably accessible to
patients and providers in this state and the department by a toll free telephone line or
by acceptance of long-distance collect calls for forty hours each week during normal
business hours.
5. A description of the policies and procedures that ensure that the utilization
review agent will follow applicable state and federal laws to protect the confidentiality
of individual medical records.
6. A copy of the materials or a description of the procedure designed to inform
patients and providers, as appropriate, of the requirements of the utilization review
plan.
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