58-17D-1      Definitions.
58-17D-2      Certain utilization review organizations exempt from managed health care provisions.
58-17D-3      Property and casualty insurers to use registered utilization review organizations.
58-17D-4      Utilization review to be administered by qualified professional.
58-17D-5      Certain basis for fees prohibited.
58-17D-6      Insurer denying policyholder's claim to provide for reconsideration.
58-17D-7      No cause of action created or abrogated.

58-17D-1. Definitions.

Terms used in this chapter mean:

(1)    "Utilization review," a review of health care services provided or to be provided to an individual to assist in the determination of the nature of the injury or condition, or the appropriateness of the treatment provided or to be provided;

(2)    "Utilization review organization," any entity that provides utilization review services as defined in this chapter.

Source: SL 2002, ch 231, § 1.

58-17D-2. Certain utilization review organizations exempt from managed health care provisions.

A utilization review organization that conducts utilization reviews solely for property and casualty insurers in this state pursuant to policies issued in this state is not subject to chapters 58-17F, 58-17G, 58-17H, and 58-17I except that any such utilization review organization shall register in the same manner as prescribed for utilization review organizations pursuant to §§ 58-17H-35 to 58-17H-39, inclusive. (SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.")

Source: SL 2002, ch 231, § 2; SL 2011, ch 219, § 97.

Commission Note: SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed."

58-17D-3. Property and casualty insurers to use registered utilization review organizations.

Any property and casualty insurer seeking utilization review with respect to an insurance contract issued in this state may only use a utilization review organization registered pursuant to this chapter.

Source: SL 2002, ch 231, § 3.

58-17D-4. Utilization review to be administered by qualified professional.

Any utilization review pursuant to this chapter shall be administered by a qualified licensed health care professional. Any adverse determination shall be evaluated by an appropriately licensed and clinically qualified health care professional. Any utilization review evaluation shall use generally accepted standards for treatment of the illness, injury, or condition reviewed. Any utilization review opinion shall be signed by the professional who performed the review.

Source: SL 2002, ch 231, § 4.

58-17D-5. Certain basis for fees prohibited.

No utilization review organization may base its fees or charges on any recommendation for reduction in payment under an insurance contract or on a percentage of claim savings.

Source: SL 2002, ch 231, § 5.

58-17D-6. Insurer denying policyholder's claim to provide for reconsideration.

An insurer that denies, in whole or in part, a policyholder's claim after consideration of a utilization review shall provide the policyholder with an opportunity to request reconsideration and to submit additional information relating to the claim.

Source: SL 2002, ch 231, § 6.

58-17D-7. No cause of action created or abrogated.

Nothing in this chapter is intended to create or abrogate any cause of action as a result of a violation of the standards in this chapter.

Source: SL 2002, ch 231, § 7.