Chapter 19: NONPROFIT HOSPITAL OR MEDICAL SERVICE ORGANIZATIONS
Subchapter 2-A: LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES HEADING: PL 1989, C. 556, PT. C, §1 (NEW)
§2343. Minimum standards
A utilization review program of the applicant must meet the following minimum standards. [1989, c. 556, Pt. C, §1 (NEW).]
1. Notification of adverse decisions. Notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within a time period to be determined by the superintendent through rulemaking.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
2. Reconsideration of determination. All licensees shall maintain a procedure by which insureds, patients or providers may seek reconsideration of determinations of the licensee.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
3. Accessibility of representatives. A representative of the licensee must be accessible by telephone to insureds, patients or providers and the superintendent may adopt standards of accessibility by rule.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
4. Information materials; confidentiality. A copy of the materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan and an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed must be filed with the bureau.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
5. Prohibited activities. A medical utilization review entity shall ensure that an employee does not perform medical utilization review services involving a health care provider or facility in which that employee has a financial interest.
Chapter 19: NONPROFIT HOSPITAL OR MEDICAL SERVICE ORGANIZATIONS
Subchapter 2-A: LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES HEADING: PL 1989, C. 556, PT. C, §1 (NEW)
§2343. Minimum standards
A utilization review program of the applicant must meet the following minimum standards. [1989, c. 556, Pt. C, §1 (NEW).]
1. Notification of adverse decisions. Notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within a time period to be determined by the superintendent through rulemaking.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
2. Reconsideration of determination. All licensees shall maintain a procedure by which insureds, patients or providers may seek reconsideration of determinations of the licensee.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
3. Accessibility of representatives. A representative of the licensee must be accessible by telephone to insureds, patients or providers and the superintendent may adopt standards of accessibility by rule.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
4. Information materials; confidentiality. A copy of the materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan and an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed must be filed with the bureau.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
5. Prohibited activities. A medical utilization review entity shall ensure that an employee does not perform medical utilization review services involving a health care provider or facility in which that employee has a financial interest.
Chapter 19: NONPROFIT HOSPITAL OR MEDICAL SERVICE ORGANIZATIONS
Subchapter 2-A: LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES HEADING: PL 1989, C. 556, PT. C, §1 (NEW)
§2343. Minimum standards
A utilization review program of the applicant must meet the following minimum standards. [1989, c. 556, Pt. C, §1 (NEW).]
1. Notification of adverse decisions. Notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within a time period to be determined by the superintendent through rulemaking.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
2. Reconsideration of determination. All licensees shall maintain a procedure by which insureds, patients or providers may seek reconsideration of determinations of the licensee.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
3. Accessibility of representatives. A representative of the licensee must be accessible by telephone to insureds, patients or providers and the superintendent may adopt standards of accessibility by rule.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
4. Information materials; confidentiality. A copy of the materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan and an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed must be filed with the bureau.
[ 1989, c. 556, Pt. C, §1 (NEW) .]
5. Prohibited activities. A medical utilization review entity shall ensure that an employee does not perform medical utilization review services involving a health care provider or facility in which that employee has a financial interest.
