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CHAPTER 58-17H

UTILIZATION REVIEW AND BENEFIT DETERMINATIONS

58-17H-1      Definitions.
58-17H-2      Health benefit plan defined.
58-17H-3      Urgent care request defined.
58-17H-4      Applicability of chapter.
58-17H-5      Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services.
58-17H-6      In-network emergency services.
58-17H-7      Cost-sharing requirements for out-of-network emergency services.
58-17H-8      Cost-sharing requirements for covered persons--Payments to out-of-network providers.
58-17H-9      Exceptions for payments by capitated and other plans without negotiated fees.
58-17H-10      Negotiated amounts for in-network providers for a particular emergency service.
58-17H-11      General cost-sharing requirements allowed.
58-17H-12      Access to representative for post-evaluation or post-stabilization services.
58-17H-13      Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body.
58-17H-14      Health carrier responsibility for utilization review activities.
58-17H-15      Director to hold health carrier responsible for utilization review performance of contractor.
58-17H-16      Written utilization review program required--Contents of program document.
58-17H-17      Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request.
58-17H-18      Program to be administered by qualified licensed health care professionals.
58-17H-19      Determinations to be issued in timely manner--Process to ensure consistency.
58-17H-20      Effectiveness and efficiency of program to be routinely reviewed.
58-17H-21      Data systems to support program activities and generate management reports.
58-17H-22      Health carrier oversight of delegated activities--Requirements.
58-17H-23      Utilization review to be coordinated with other medical management activity of health carrier.
58-17H-24      Health carrier to provide free access to review staff.
58-17H-25      Only information necessary for review or determination to be collected.
58-17H-26      Independence and impartiality required for utilization review.
58-17H-27      Written procedures required for making determinations--Notification.
58-17H-28      Prospective review determinations--Timing--Notification of requirements--Extension of time.
58-17H-29      Concurrent review determinations--Timing--Notification requirements.
58-17H-30      Retrospective review determinations--Timing--Notification requirements.
58-17H-31      Calculation of time period for determination for prospective and retrospective reviews.
58-17H-32      Notification of adverse determination--Contents.
58-17H-33      Information required to be provided to covered persons and prospective covered persons.
58-17H-34      Health carrier may be deemed to meet utilization review requirements if met by private accrediting body.
58-17H-35      Registration of utilization review organizations--Required information.
58-17H-36      Filing changes in registration information.
58-17H-37      Requests for information from utilization review organizations.


58-17H-38      Activities of nonregistered utilization review organizations prohibited.
58-17H-39      Registration fee for utilization review organizations.
58-17H-40      Urgent care requests--Written procedures required for receipt and determination of requests.
58-17H-41      Insufficient information for determination--Notice and statement of necessary information.
58-17H-42      Insufficient information for determination of prospective urgent care requests.
58-17H-43      Urgent care requests--Timely notification of determination.
58-17H-44      Time within which to submit necessary information.
58-17H-45      Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification.
58-17H-46      Concurrent review urgent care requests--Extended care requests--Time for determination and notice.
58-17H-47      Calculation of time periods for determination.
58-17H-48      Notification of adverse determination--Requirements.
58-17H-49      Promulgation of rules.
58-17H-50      Coverage for cancer treatment medication.
58-17H-51      Reclassification of benefits with respect to cancer treatment medications.
58-17H-52      Medical management practices complying with chapter.


Back to Title 58