UTILIZATION REVIEW AND BENEFIT DETERMINATIONS
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.
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.
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