Chapter 350

2003 -- H 6528

Enacted 07/17/03

AN ACT

RELATING TO HEALTH AND SAFETY

Introduced By: Representative Thomas Winfield

Date Introduced: June 17, 2003

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 the time that

the department promulgates regulations, develops required forms, and has acted on the

application submitted by the review agent.

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 any 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, 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 the 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;

(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, is 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 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 the consultation

for all screening and review criteria to be utilized. Utilization review agents who have been

certified for one year or longer shall be required to conduct the 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 the consultations as required under

paragraph (i) of this subdivision, 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) of this subdivision.

(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. The

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) of this

subdivision, 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, or otherwise

provided for, an equivalent two-way direct communication with 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. The

review agent is required to accept a verbal request made by or on behalf of a patient for any

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 that 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 any means 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 any fees for initial application,

renewal applications, and any other administrative actions 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 upon passage.

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LC03450

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