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    (Section effective January 1, 2016) Coverage for cancer treatment medication.

58-17H-51    (Section effective January 1, 2016) Reclassification of benefits with respect to cancer treatment medications.

58-17H-52    (Section effective January 1, 2016) Medical management practices complying with chapter.

58-17H-53    Step therapy protocols.

58-17H-54    Step therapy protocols--Process--Transparency.

58-17H-55    Step therapy override exceptions.

58-17H-56    Limitations.