20-2510

20-2510. Health care insurers requirements;
medical directors

A. A health care insurer that proposes to provide coverage of inpatient hospital
and medical benefits, outpatient surgical benefits or any medical, surgical or health
care service for residents of this state with utilization review of those benefits shall
meet at least one of the following requirements:

1. Have a certificate issued pursuant to this chapter.

2. Be accredited by the utilization review accreditation commission, the national
committee for quality assurance or any other nationally recognized accreditation process
recognized by the director.

3. Contract with a utilization review agent that has a certificate issued pursuant
to this chapter.

4. Contract with a utilization review agent that 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.

5. Provide to the director a signed and notarized statement that the health care
insurer has submitted an application for accreditation to the utilization review
accreditation commission or the national committee for quality assurance and is awaiting
completion of the accreditation review process. On completion of the accreditation
review process, the insurer shall provide to the director adequate proof that the insurer
has been accredited. If the insurer is denied accreditation, within sixty days after the
denial the insurer shall meet at least one of the requirements set forth in paragraph 1,
2, 3 or 4 of this subsection.

B. Except as provided in subsections C, D and E of this section, any direct denial
of prior authorization of a service requested by a health care provider on the basis of
medical necessity by a health care insurer shall be made in writing by a medical director
who holds an active unrestricted license to practice medicine in this state pursuant to
title 32, chapter 13 or 17. The written denial shall include an explanation of why the
treatment was denied, and the medical director who made the denial shall sign the written
denial. The health care insurer shall send a copy of the written denial to the health
care provider who requested the treatment. Health care insurers shall maintain copies of
all written denials and shall make the copies available to the department for inspection
during regular business hours. The medical director is responsible for all direct denials
that are made on the basis of medical necessity. Nothing in this section prohibits a
health care insurer from consulting with a licensed physician whose scope of practice may
provide the health care insurer with a more thorough review of the medical necessity.

C. For determinations made pursuant to subsection B of this section, a dental
service corporation as defined in section 20-822 or a prepaid dental plan organization as
defined in section 20-1001 may use as a medical director either:

1. An individual who holds an active unrestricted license to practice dentistry in
this state pursuant to title 32, chapter 11.

2. A physician who holds an active unrestricted license to practice medicine in
this state pursuant to title 32, chapter 13 or 17.

D. For determinations made pursuant to subsection B of this section, an optometric
service corporation may use as a medical director either:

1. An individual who holds an active unrestricted license to practice optometry in
this state pursuant to title 32, chapter 16.

2. A physician who holds an active unrestricted license to practice medicine in
this state pursuant to title 32, chapter 13 or 17.

E. For determinations made pursuant to subsection B of this section, a health care
insurer may use a chiropractor licensed in this state pursuant to title 32, chapter 8 or
by any regulatory board in another state to review any direct denial of prior
authorization of a chiropractic service requested by a chiropractor on the basis of
medical necessity.