[§334B-3]  Standards for review agents. (a)  A review agent who approves or denies payment, or who recommendsapproval or denial of payment for mental health, alcohol, or drug abusetreatment services, or whose review results in approval or denial of paymentfor these services on a case by case basis, shall conduct utilization review ormanaged care in this State subject to administrative rules developed by thedirector.

(b)  The director shall establish a complaintresolution panel which shall review any complaints about review agents todetermine the facts and establish whether the standards are being followed.  Ifthe panel finds consistent violation of the standards, a fiscal penalty may beimposed on the review agent.

(c)  The director shall adopt rules pursuant tochapter 91 necessary for the purposes of this chapter.  No later than one yearafter January 1, 1992, the director shall adopt rules establishing:

(1)  A requirement that the review agent providepatients and providers with its utilization review or managed care planincluding the specific review criteria and standards, procedures and methods tobe used in evaluating proposed or delivered mental health, alcohol, or drugabuse treatment services;

(2)  A requirement that no determination adverse to apatient or to any affected health care provider shall be made on any questionrelating to the necessity or justification for any form of mental health,alcohol, or drug abuse treatment services without prior evaluation andconcurrence in the adverse determination by another professional withcomparable qualifications in a timely manner;

(3)  A requirement that a denial of third-partyreimbursement or a denial of prior authorization for that service shall includethe written evaluation, findings, and concurrence of a professional withcomparable qualifications in the relevant specialty or sub-specialty to make afinal determination that care rendered or to be rendered was, is, or may beinappropriate;

(4)  Provisions by which patients, mental health,alcohol, or drug abuse treatment providers may seek prompt reconsideration byor appeal to the complaint resolution panel of adverse decisions by the reviewagent;

(5)  A requirement that a review agent obtainpermission from both the patient and the attending professional prior toattending a treatment session;

(6)  A requirement that a representative of the reviewagent is reasonably accessible to patients, the patient’s family, and providersat least five days a week during normal business hours and that payment may notbe denied solely because the review agent is not available;

(7)  Policies and procedures to ensure that allapplicable state and federal laws protecting the confidentiality of individualmedical records are followed;

(8)  Policies and procedures to ensure that the amountor type of information requested by any system of managed care or utilizationreview be minimal, be pertinent to the needs of providing appropriateutilization review or managed care services, and shall not violate patientrights and confidentiality;

(9)  A requirement that the referring professional beinformed prior to the decision for a denial of treatment benefits; providedthat, once the adverse determination has been made, this decision shall becommunicated in a timely [manner] to all affected parties;

(10)  A prohibition of a contract provision between oramong any combination of the review agent, the provider, a business entity, orthird-party payor that may constitute a conflict of interest;

(11)  A requirement that an orderly process beestablished for the timely and impartial internal resolution of problems priorto the use of the complaint process; and

(12)  The process by which complaints shall be handledby the complaint resolution panel.

(d)  Nothing in this process shall be deemed todeprive a patient or mental health, alcohol, or drug abuse treatment providerof any other cause of action available under state law. [L 1991, c 95, pt of§1]

 

Revision Note

 

  "January 1, 1992" substituted for "theeffective date of this chapter".