A N A C T
RELATING TO HEALTH AND SAFETY -- HEALTH CARE SERVICES -- UTILIZATION REVIEW ACT
It is enacted by the General Assembly as follows:
SECTION 1. Section 23-17.12-3 of the General Laws in Chapter 23-17.12 entitled "Health Care Services - Utilization Review Act" is hereby amended to read as follows:
23-17.12-3. Regulation of review agents - Certificate. -- (a) A review agent shall not conduct utilization review in the state unless the department has granted the review agent a certificate.
(b) Review agents who are operating in Rhode Island prior to the promulgation of regulations pursuant to this chapter may continue to conduct utilization review until such time as the department promulgates regulations, develops required forms, and has acted on the application submitted by the review agent.
(c) Individuals shall not be required to hold separate certification under this chapter when acting as either an employee of, an affiliate of, a contractor for, or otherwise acting on behalf of a certified review agent.
(d) The department shall issue a certificate to an applicant that has met the minimum standards established by this chapter, and regulations promulgated in accordance with it, including the payment of such fees as required, and other applicable regulations of the department.
(e) A certificate issued under this chapter is not transferable; and the transfer of fifty percent (50%) or more of the ownership of a review agent shall be deemed a transfer.
(f) After consultation with the payers and providers of health care, no later than one year after January 1, 1993, the department shall adopt regulations necessary to implement the provisions of this chapter including but not limited to the following:
(1) The requirement that the review agent provide patients and providers with a summary of its utilization review plan including a summary of the standards, procedures and methods to be used in evaluating proposed or delivered health care services;
(2) The circumstances, if any, under which utilization review may be delegated to any other utilization review program and evidence that such delegated agency is a certified utilization review agency pursuant to the requirements of this chapter;
(3) A complaint resolution process, acceptable to the department whereby patients, their physicians or other health care providers may seek prompt reconsideration or appeal of adverse decisions by the review agent, as well as the resolution of complaints and other matters of which the review agent has received written notice thereof;
(4) The type and qualifications of personnel authorized to perform utilization review, including a requirement that only a practitioner with the same status as the ordering practitioner, or a licensed physician or dentist, be permitted to make a prospective or concurrent adverse determination;
(5) The requirement that each review agent shall utilize and provide, as determined appropriate by the director, to Rhode Island licensed hospitals and the RI Medical Society, in either electronic or paper format, written medically acceptable screening criteria and review procedures which are established and periodically evaluated and updated with appropriate consultation with Rhode Island licensed physicians, hospitals, including practicing physicians, and other health care providers. in the same specialty as would typically treat the services subject to the criteria as follows:
(i) Utilization review agents shall consult with no fewer than five (5) Rhode Island licensed physicians or other health care providers. Further, in instances where the screening criteria and review procedures are applicable to inpatients and/or outpatients of hospitals, the medical director of each such licensed hospital in Rhode Island shall also be consulted. Utilization review agents who utilize screening criteria and review procedures provided by another entity may satisfy the requirements of this section if the utilization review agent demonstrates to the satisfaction of the director that the entity furnishing the screening criteria and review procedures has complied with the requirements of this section.
(ii) Utilization review agents seeking initial certification shall conduct such consultation for all screening and review criteria to be utilized. Utilization review agents who have been certified for one (1) year or longer shall be required to conduct such consultation on a periodic basis for the utilization review agent's highest volume services subject to utilization review during the prior year; services subjected to the highest volume of adverse determinations during the prior year; and for any additional services identified by the director.
(iii) Utilization review agents shall not include in such consultations as required under paragraph (i) above, any physicians or other health services providers who have financial relationships with the utilization review agent other than financial relationships for provision of direct patient care to utilization review agent enrollees and reasonable compensation for consultation as required by paragraph (i) above.
(iv) All documentation regarding required consultations, including comments and/or recommendations provided by the health care providers involved in the review of the screening criteria, as well as the utilization review agent's action plan or comments on any recommendations, shall be in writing and shall be furnished to the department on request. Such documentation shall also be provided on request to any licensed health care provider at a nominal cost that is sufficient to cover the utilization review agent's reasonable costs of copying and mailing.
(v) Utilization review agents may utilize non-Rhode Island licensed physicians or other health care providers to provide the consultation as required under paragraph (i) above, when the utilization review agent can demonstrate to the satisfaction of the director that the related services are not currently provided in Rhode Island or that another substantial reason requires such approach.
(vi) Utilization review agents whose annualized data reported to the department demonstrate that the utilization review agent will review fewer than five hundred (500) such requests for authorization may request a variance from the requirements of this section.
(6) The requirement that, other than in exceptional circumstances, or when the patient's attending physician or dentist is not reasonably available, no adverse determination that care rendered or to be rendered is medically inappropriate shall be made until an appropriately qualified and licensed review physician, dentist, or other practitioner has spoken to the patient's attending physician, dentist, or other practitioner concerning the medical care;
(7) The requirement that, upon written request made by or on behalf of a patient, any determination that care rendered or to be rendered is medically inappropriate shall include the written evaluation and findings of the reviewing physician, dentist, or other practitioner; provided, however, that the review agent is required to accept a verbal request made by or on behalf of a patient for such information where a provider or patient can demonstrate that a timely response is urgent; the verbal request must be confirmed in writing within seven (7) days;
(8) The requirement that a representative of the review agent is reasonably accessible to patients, patient's family, and providers at least five (5) days a week during normal business in Rhode Island and during the hours of the agency's review operations.
(9) The policies and procedures to ensure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed;
(10) The policies and procedures regarding the notification and conduct of patient interviews by the review agent.
(11) The requirement that no employee of, or other individual rendering an adverse determination for, a review agent may receive any financial incentives based upon the number of denials of certification made by such employee or individual.
(12) The requirement that the utilization review agent shall not impede the provision of health care services for treatment and/or hospitalization or other use of a provider's services or facilities for any patient for whom the treating provider determines the health care service to be of an emergency nature. The emergency nature of the health care service shall be documented and signed by a licensed physician, dentist, or other practitioner and may be subject to review by a review agent.
(13) The requirement that a review agent shall make a determination, and shall communicate that determination within time frames and by such means as specified by the department; and
(14) The requirement that except in circumstances as may be allowed by regulations promulgated pursuant to this chapter, no adverse determination shall be made on any question relating to health care and/or medical services by any person other than an appropriately licensed physician, dentist, or other practitioner, which determination shall be discussed by the reviewing practitioner with the affected provider or other designated or qualified professional or provider responsible for treatment of the patient.
(g) The director of health is authorized to establish such fees for initial application, renewal applications, and such other administrative actions as deemed necessary by the director to implement this chapter.
(h) The total cost of certification under this title shall be borne by the certified entities and shall be one hundred and fifty percent (150%) of the total salaries paid to the certifying personnel of the department engaged in those certifications less any salary reimbursements and shall be paid to the director to and for the use of the department. That assessment shall be in addition to any taxes and fees otherwise payable to the state.
SECTION 2. This act shall take effect on January 1, 2002.