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



(b)  The director shall establish a complaint
resolution panel which shall review any complaints about review agents to
determine the facts and establish whether the standards are being followed.  If
the panel finds consistent violation of the standards, a fiscal penalty may be
imposed on the review agent.



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



(1)  A requirement that the review agent provide
patients and providers with its utilization review or managed care plan
including the specific review criteria and standards, procedures and methods to
be used in evaluating proposed or delivered mental health, alcohol, or drug
abuse treatment services;



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



(3)  A requirement that a denial of third-party
reimbursement or a denial of prior authorization for that service shall include
the written evaluation, findings, and concurrence of a professional with
comparable qualifications in the relevant specialty or sub-specialty to make a
final determination that care rendered or to be rendered was, is, or may be
inappropriate;



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



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



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



(7)  Policies and procedures to ensure that all
applicable state and federal laws protecting the confidentiality of individual
medical records are followed;



(8)  Policies and procedures to ensure that the amount
or type of information requested by any system of managed care or utilization
review be minimal, be pertinent to the needs of providing appropriate
utilization review or managed care services, and shall not violate patient
rights and confidentiality;



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



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



(11)  A requirement that an orderly process be
established for the timely and impartial internal resolution of problems prior
to the use of the complaint process; and



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



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



 



Revision Note



 



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