Chapter
06-221
2006 -- H 7654 SUBSTITUTE B
Enacted 07/03/06
A N A C T
RELATING
TO HEALTHCARE SERVICES - UTILIZATION REVIEW ACT
Introduced
By: Representatives Costantino, Carter, and Pacheco
Date
Introduced: February 16, 2006
It is enacted by the General Assembly as
follows:
SECTION 1.
Sections 23-17.12-2, 23-17.12-3, 23-17.12-4, 23-17.12-5, 23-17.12-8 and
23-17.12-9 of the General Laws in Chapter
23-17.12 entitled "Health Care Services - Utilization
Review Act" are hereby amended to read as
follows:
23-17.12-2.
Definitions. -- As used in this chapter, the following terms are
defined as
follows:
(1) "Adverse
determination" means any a utilization review decision by a
review agent
not to certify authorize a health
care service. A decision by a review agent to certify authorize a
health care service in an alternative setting, a
modified extension of stay, or an alternative
treatment shall not constitute an adverse
determination if the review agent and provider are in
agreement regarding the decision. Adverse
determinations include decisions not to certify
authorize formulary and nonformulary medication.
(2)
"Appeal" means a subsequent review of an adverse determination upon
request by a
patient or provider to reconsider all or part of
the original decision.
(3)
"Authorization" means the review agent's utilization review,
performed according to
subsection 23-17.12-2(20), concluded that the
allocation of health care services of a provider,
given or proposed to be given to a patient was
approved or authorized.
(4)
"Benefit determination" means a decision of the enrollee's
entitlement to payment for
covered health care services as defined in an
agreement with the payor or its delegate.
(2) (5)
"Certificate" means a certificate of registration granted by the
director to a review
agent.
(6)
"Complaint" means a written expression of dissatisfaction by a
patient, or provider.
The appeal of an adverse determination is not
considered a complaint.
(7)
"Concurrent assessment" means an assessment of the medical necessity
and/or
appropriateness of health care services
conducted during a patient's hospital stay or course of
treatment. If the medical problem is ongoing,
this assessment may include the review of services
after they have been rendered and billed. This
review does not mean the elective requests for
clarification of coverage or claims review or a
provider's internal quality assurance program
except if it is associated with a health care
financing mechanism.
(3) (8)
"Department" means the department of health.
(4) (9)
"Director" means the director of the department of health.
(5) (10)
"Emergent health care services" has the same meaning as that meaning
contained in the rules and regulations
promulgated pursuant to chapter 12.3 of title 42 as may be
amended from time to time and includes those
resources provided in the event of the sudden onset
of a medical, mental health, or substance abuse
or other health care condition manifesting itself
by acute symptoms of a severity (e.g. severe
pain) where the absence of immediate medical
attention could reasonably be expected to result
in placing the patient's health in serious jeopardy,
serious impairment to bodily or mental
functions, or serious dysfunction of any body organ or
part.
(6) (11)
"Patient" means an enrollee or participant in all hospital or medical
plans
seeking health care services and treatment from
a provider.
(12)
"Payor" means a health insurer, self-insured plan, nonprofit health
service plan,
health insurance service organization, preferred
provider organization, health maintenance
organization or other entity authorized to offer
health insurance policies or contracts or pay for
the delivery of health care services or
treatment in this state.
(7) (13)
"Practitioner" means any person licensed to provide or otherwise
lawfully
providing health care services, including, but
not limited to, a physician, dentist, nurse,
optometrist, podiatrist, physical therapist,
clinical social worker, or psychologist.
(14)
"Prospective assessment" means an assessment of the medical necessity
and/or
appropriateness of health care services prior to
services being rendered.
(8) (15)
"Provider" means any health care facility, as defined in section
23-17-2
including any mental health and/or substance
abuse treatment facility, physician, or other licensed
practitioners identified to the review agent as
having primary responsibility for the care,
treatment, and services rendered to a patient.
(16)
"Retrospective assessment" means an assessment of the medical
necessity and/or
appropriateness of health care services that
have been rendered. This shall not include reviews
conducted when the review agency has been
obtaining ongoing information.
(9) (17)
"Review agent" means a person or entity or insurer performing
utilization
review that is either employed by, affiliated
with, under contract with, or acting on behalf of:
(i) A business
entity doing business in this state;
(ii) A party that
provides or administers health care benefits to citizens of this state,
including a health insurer, self-insured plan,
non-profit health service plan, health insurance
service organization, preferred provider
organization or health maintenance organization
authorized to offer health insurance policies or
contracts or pay for the delivery of health care
services or treatment in this state; or
(iii) A provider.
(18) "Same
or similar specialty" means a practitioner who has the appropriate
training
and experience that is the same or similar as
the attending provider in addition to experience in
treating the same problems to include any
potential complications as those under review.
(10) (19)
"Urgent health care services" has the same meaning as that meaning
contained
in the rules and regulations promulgated
pursuant to chapter 12.3 of title 42 as may be amended
from time to time and includes those resources
necessary to treat a symptomatic medical, mental
health, or substance abuse or other health care
condition requiring treatment within a twenty-four
(24) hour period of the onset of such a
condition in order that the patient's health status not
decline as a consequence. This does not include
those conditions considered to be emergent
health care services as defined in subdivision (5)
(10).
(11) (20)
"Utilization review" means the prospective, concurrent, or
retrospective
assessment of the necessity and/or
appropriateness of the allocation of health care services of a
provider, given or proposed to be given to a
patient or group of patients. Utilization review does
not include:
(i) Elective
requests for the clarification of coverage; or
(ii) Benefit
determination; or
(ii) (iii)
Claims review that does not include the assessment of the medical necessity and
appropriateness; or
(iii) (iv)
A provider's internal quality assurance program except if it is associated with
a
health care financing mechanism; or
(iv) (v)
The therapeutic interchange of drugs or devices by a pharmacy operating as part
of a licensed inpatient health care facility; or
(v) (vi)
The assessment by a pharmacist licensed pursuant to the provisions of chapter
19
of title 5 and practicing in a pharmacy
operating as part of a license licensed inpatient health care
facility in the interpretation, evaluation and
implementation of medical orders, including
assessments and/or comparisons involving
formularies and medical orders.
(12) (21)
"Utilization review plan" means a description of the standards
governing
utilization review activities performed by a
private review agent.
(13) (22)
"Health care services" means and includes an admission, diagnostic
procedure,
therapeutic procedure, treatment, extension of
stay, the ordering and/or filling of formulary or
nonformulary medications, and any other
services, activities, or supplies that are covered by the
patient's benefit plan.
(14) (23)
"Therapeutic interchange" means the interchange or substitution of a
drug with
a dissimilar chemical structure within the same
therapeutic or pharmacological class that can be
expected to have similar outcomes and similar
adverse reaction profiles when given in equivalent
doses, in accordance with protocols approved by
the president of the medical staff or medical
director and the director of pharmacy.
23-17.12-3.
General certificate requirements. -- (a) A review agent shall not
conduct
utilization review in the state unless the
department has granted the review agent a certificate.
(b) 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.
(c) 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.
(d) 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.
(e) After
consultation with the payers payors and providers of health care,
the
department shall adopt regulations necessary to
implement the provisions of this chapter.
(f) 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.
(g) 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.
(h) The
application and other fees required under this chapter shall be sufficient to
pay
for the administrative costs of the certificate
program and any other reasonable costs associated
with carrying out the provisions of this
chapter.
(i) A certificate
expires on the second anniversary of its effective date unless the
certificate is renewed for a two (2) year term
as provided in this chapter.
(j) Any systemic
changes in the review agents operations relative to certification
information on file shall be submitted to the
department for approval within thirty (30) days prior
to implementation.
23-17.12-4.
Application process. -- (a) An applicant requesting certification or
recertification shall:
(1) Submit an
application provided by the director; and
(2) Pay the
application fee established by the director through regulation and section 23-
17.12-3(f).
(b) The
application shall:
(1) Be on a form
and accompanied by supporting documentation that the director
requires; and
(2) Be signed and
verified by the applicant.
(c) Before the
certificate expires, a certificate may be renewed for an additional two (2)
years.
(d) If a
completed application for recertification is being processed by the department,
a
certificate may be continued until a renewal
determination is made.
(e) In
conjunction with the application, the review agent shall submit information
that
the director requires including:
(1) A request
that the state agency regard specific portions of the standards and criteria
or the entire document to constitute "trade
secrets" within the meaning of that term in section 38-
2-2(4)(i)(B);
(2) The policies
and procedures to ensure that all applicable state and federal laws to
protect the confidentiality of individual
medical records are followed;
(3) A copy of the
materials used to inform enrollees of the requirements under the health
benefit plan for seeking utilization review or
pre-certification and their rights under this chapter,
including information on appealing adverse
determinations;
(4) A copy of the
materials designed to inform applicable patients and providers of the
requirements of the utilization review plan;
(5) A list of the
third party payers payors and business entities for which the
review
agent is performing utilization review in this
state and a brief description of the services it is
providing for each client; and
(6) Evidence of
liability insurance or of assets sufficient to cover potential liability.
(f) The
information provided must demonstrate that the review agent will comply with
the regulations adopted by the director under
this chapter.
23-17.12-5.
General application requirements. -- An application for certification
or
recertification shall be accompanied by
documentation to evidence the following:
(a) 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;
(b) 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 delegated to perform
utilization review pursuant to all of the requirements of this
chapter;
(c) A complaint
resolution process, consistent with section 23-17.12-9 subsection
23-
17.12-2(6) and 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;
(d) The type and
qualifications of personnel (employed or under contract) authorized to
perform utilization review, including a
requirement that only a practitioner with the same
licensure status as the ordering practitioner, or a
licensed physician or dentist, is permitted to
make a prospective or concurrent adverse
determination;
(e) 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;
(f) The policies
and procedures to ensure that all applicable state and federal laws to
protect the confidentiality of individual
medical records are followed;
(g) The policies
and procedures regarding the notification and conduct of patient
interviews by the review agent;
(h) 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;
(i) 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;
(j) Evidence that
the review agent has not entered into a compensation agreement or
contract with its employees or agents whereby
the compensation of its employees or its agents is
based upon a reduction of services or the
charges for those services, the reduction of length of
stay, or utilization of alternative treatment
settings; provided, nothing in this chapter shall prohibit
agreements and similar arrangements; and
(k) An adverse
determination and internal appeal appeals process as required
by this
chapter. consistent with section 23-17.12-9 and
acceptable to the department, whereby patients,
their physicians, or other health care providers
may seek prompt reconsideration or appeal of
adverse determinations by the review agent.
23-17.12-8.
Waiver of requirements. -- (a) Except for utilization review agencies
performing utilization review activities performed
to determine the necessity and/or
appropriateness of substance abuse and mental
health care, treatment or services, the department
shall waive all the requirements of this
chapter, with the exception of those contained in sections
23-17.12-9, (a)(1)-(3), (5), (6), (8),
(b)(1)-(6), and (c)(2)-(6), 23-17.12-12, and 23-17.12-14, for a
review agent that has received, maintains and
provides evidence to the department of
accreditation from the utilization review
accreditation commission (URAC) or other organization
approved by the director. The waiver shall be
applicable only to those services that are included
under the accreditation by the utilization
review accreditation commission or other approved
organization.
(b) The
department shall waive the requirements of this chapter only when a direct
conflict exists with those activities of a
review agent that are conducted pursuant to contracts with
the state or the federal government or those
activities under other state or federal jurisdictions.
(c) The
limitation in subsection 23-17.12-8(b) notwithstanding, the department may
waive or exempt all or part of the requirements
of this chapter by mutual written agreement with
a state department or agency when such waiver or
exemption is determined to be necessary and
appropriate to the administration of a health
care related program. The department shall
promulgate such regulations as deemed
appropriate to implement this provision.
23-17.12-9.
Review agency requirement for adverse determination and internal
appeals. -- (a) The decision
adverse determination and appeals process of the review agent shall
conform to the following:
(1) Notification
of a prospective adverse determination by the review agent shall be
mailed or otherwise communicated to the provider
of record and to the patient or other
appropriate individual within one business
day of the receipt of all information necessary to
complete the review unless otherwise determined
by the department in regulation for nonurgent
and nonemergency services. as follows:
(i) Within
fifteen (15) business days of receipt of all the information necessary to
complete a review of non-urgent and/or
non-emergent services;
(ii) Within
seventy-two (72) hours of receipt of all the information necessary to complete
a review of urgent and/or emergent services; and
(iii) Prior to
the expected date of service.
(2) Notification
of a concurrent adverse determination shall be mailed or otherwise
communicated to the patient and to the provider
of record prior to the end of the current certified
period as follows: consistent with
time frames to be established in regulations promulgated by the
department.
(i) To the
provider(s) prior to the end of the current certified period; and
(ii) To the
patient within one business day of making the adverse determination.
(3) Notification
of a retrospective adverse determination shall be mailed or otherwise
communicated to the patient and to the provider
of record within thirty (30) business days of
receipt of a request for payment with all
supporting documentation for the covered benefit being
reviewed.
(4) A utilization
review agency shall not retrospectively deny coverage authorization
for
health care services provided to a covered
person when prior approval an authorization has been
obtained for that service from the review
agent unless the approval was based upon inaccurate
information material to the review or the health
care services were not provided consistent with
the provider's submitted plan of care and/or any
restrictions included in the prior approval granted
by the review agent.
(5) Any notice of
a an adverse determination not to certify a health care
service shall be
made, documented, and signed and shall be mailed
or otherwise communicated, and shall include:
(i) The principal
reasons for the adverse determination, and to include explicit
documentation of the criteria not met and/or the
clinical rationale utilized by the agency's clinical
reviewer in making the adverse determination.
The criteria shall be in accordance with the agency
criteria noted in subsection 23-17.12-9(d) and
shall be made available within the first level appeal
timeframe if requested unless otherwise provided
as part of the adverse determination notification
process;
(ii) The
procedures to initiate an appeal of the adverse determination,
including or the
name and telephone number of the person to
contract with regard to an appeal. ;
(iii) The
necessary contact information to complete the two-way direct communication
defined in subdivision 23-17.12-9 (a)(7); and
(iv) The
information noted in subdivision 23-27.12-9(a)(5)(i)(ii)(iii) for all verbal
notifications followed by written notification
to the patient and provider(s).
(6) All initial
retrospective adverse determinations of a health care service that had been
ordered by a physician, dentist or other
practitioner shall be made, documented and signed
consistent with the regulatory requirements
which shall be developed by the department with the
input of review agents, providers and other
affected parties.
(7) The
requirement that, other than in exceptional circumstances, or when the
patient's
attending physician or dentist is not reasonably
available, no
A level one appeal decision of an
adverse determination that care rendered or
to be rendered is medically inappropriate shall not 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, other
practitioner, other designated or qualified professional
or provider responsible for treatment of the
patient concerning the medical care. , with the
exception of the following:
(i) When the
attending provider is not reasonably available;
(ii) When the
attending provider chooses not to speak with agency staff;
(iii) When the
attending provider has negotiated an agreement with the review agent for
alternative care; and/or
(iv) When the
attending provider requests a peer to peer communication prior to the
adverse determination, the review agency shall
then comply with subdivision 23-17.12-9(c)(1) in
responding to such a request. Such requests
shall be on the case specific basis unless otherwise
arranged for in advance by the provider.
(8) All initial,
prospective and concurrent adverse determinations of a health care service
that had been ordered by a physician, dentist or
other practitioner shall be made, documented and
signed by a licensed practitioner with the same
licensure status as the ordering practitioner or a
licensed physician or dentist. This does not
prohibit appropriately qualified review agency staff
from engaging in discussions with the attending
provider, the attending provider's designee or
appropriate health care facility and office
personnel regarding alternative service and treatment
options. Such a discussion shall not constitute
an adverse determination provided though that any
change to the provider's original order and/or any
decision for an alternative level of care must be
made and/or appropriately consented to by the
attending provider or the provider's designee
responsible for treating the patient.
(9) 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.
(10) (9)
The requirement that, upon written request made by or on behalf of a patient,
any adverse determination and/or
appeal 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.
(b) The review
agent shall conform to the following for the appeal of an adverse
determination:
(1) The review
agent shall maintain and make available a written description of the
appeal procedure by which either the patient or
the provider of record may seek review of
determinations not to certify authorize
a health care service. The process established by each
review agent may include a reasonable period
within which an appeal must be filed to be
considered and that period shall not be less
than sixty (60) days.
(2) The review
agent shall notify, in writing, the patient and provider of record of its
decision on the appeal as soon as practical, but
in no case later than fifteen (15) or twenty-one
(21) working business days if
verbal notice is given within fifteen (15) working business days
after receiving the required documentation on
the appeal.
(3) The review
agent shall also provide for an expedited appeals process for emergency
or life threatening situations. Each review
agent shall complete the adjudication of expedited
appeals within two (2) business days of the date
the appeal is filed and all information necessary
to complete the appeal is received by the review
agent.
(4) All first
level appeals of determinations not to authorize a health care service that had
been ordered by a physician, dentist, or other
practitioner shall be made, documented, and signed
by a licensed practitioner with the same
licensure status as the ordering practitioner or a licensed
physician or a licensed dentist.
(4)(5)
In cases where an initial appeal to reverse an adverse determination is
unsuccessful, the review agent shall assure that All second level
appeal decisions shall be made,
signed, and documented by a licensed practitioner
with the same licensure status as the ordering
practitioner or a licensed physician in the same
or a similar general specialty as typically manages
the medical condition, procedure, or treatment
under discussion conducts the next level of review.
(5)(6)
The review agent shall maintain records of written appeals and their
resolution,
and shall provide reports as requested by the
department.
(6) All first
level appeals of determinations not to certify a health care service that had
been ordered by a physician, dentist, or other
practitioner shall be made, documented, and signed
by a licensed practitioner with the same
licensure status as the ordering practitioner or a licensed
physician or a licensed dentist.
(c) The review
agency must conform to the following requirements when making its
adverse determination and appeal decisions:
(1) The review
agent must assure that the licensed practitioner or licensed physician is
reasonably available to review the case as
required under subsection 23-17.12-3(e). subdivision
23-17.12-9(a)(7) and shall conform to the
following:
(i) Each agency
peer reviewer shall have access to and review all necessary information
as requested by the agency and/or submitted by
the provider(s) and/or patients;
(ii) Each
agency shall provide accurate peer review contact information to the provider
at
the time of service, if requested, and/or prior
to such service, if requested. This contact
information must provide a mechanism for direct
communication with the agency's peer
reviewer;
(iii) Agency
peer reviewers shall respond to the provider's request for a two-way direct
communication defined in subdivision
23-17.12-9(a)(7)(iv) as follows:
(a) For a
prospective review of non-urgent and non-emergent health care services, a
response within one (1) business day of the
request for a peer discussion;
(b) For
concurrent and prospective reviews of urgent and emergent health care services,
a
response within a reasonable period of time of
the request for a peer discussion; and
(c) For
retrospective reviews, prior to the first level appeal decision.
(iv) The review
agency will have met the requirements of a two-way direct
communication, when requested and/or as required
prior to the first level of appeal, when it has
made two (2) reasonable attempts to contact the
attending provider directly.
(v) Repeated
violations of this section shall be deemed to be substantial violations
pursuant to section 23-17.12-14 and shall be
cause for the imposition of penalties under that
section.
(2) No reviewer at
any level under this section shall be compensated or paid a bonus or
incentive based on making or upholding an
adverse determination.
(3) No reviewer
under this section who has been involved in prior reviews of the case
under appeal or who has participated in the
direct care of the patient may participate as the sole
reviewer in reviewing a case under appeal;
provided, however, that when new information has
been made available at the first level of
appeal, then the review may be conducted by the same
reviewer who made the initial adverse
determination.
(4) A review
agent is only entitled to review information or data relevant to the
utilization review process. A review agent may
not disclose or publish individual medical records
or any confidential medical information obtained
in the performance of utilization review
activities. A review agent shall be considered a
third party health insurer for the purposes of
section 5-37.3-6(b)(6) of this state and shall
be required to maintain the security procedures
mandated in section 5-37.3-4(c).
(5)
Notwithstanding any other provision of law, the review agent, the department,
and all
other parties privy to information which is the
subject of this chapter shall comply with all state
and federal confidentiality laws, including, but
not limited to, chapter 37.3 of title 5
(Confidentiality of Health Care Communications
and Information Act) and specifically section 5-
37.3-4(c), which requires limitation on the
distribution of information which is the subject of this
chapter on a "need to know" basis, and
section 40.1-5-26.
(6) The
department may, in response to a complaint that is provided in written form to
the review agent, review an appeal regarding any
adverse determination, and may request
information of the review agent, provider or
patient regarding the status, outcome or rationale
regarding the decision.
(d) The
requirement that each review agent shall utilize and provide upon request,
as
determined appropriate by the director, to by Rhode Island
licensed hospitals and the Rhode
Island 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:
(1) 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.
(2) 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 subject to the highest
volume of adverse determinations during the prior year;
and for any additional services identified by
the director.
(3) Utilization
review agents shall not include in the consultations as required under
paragraph (1) of this subdivision, any
physicians or other health services providers who have
financial relationships with the utilization
review agent other than financial relationships for
provisions of direct patient care to utilization
review agent enrollees and reasonable compensation
for consultation as required by paragraph (1) of
this subdivision.
(4) 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.
(5) Utilization
review agents may utilize non-Rhode Island licensed physicians or other
health care providers to provide the
consultation as required under paragraph (1) 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.
(6) 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.
SECTION 2. This
act shall take effect on January 1, 2007.
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LC02289/SUB
B/2
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