760 IAC 1-46-4 - General standards of utilization review
Authority: IC 27-8-17-20
Affected: IC 27-8-17
Sec. 4.
The utilization review plan, including appeal requirements, shall be conducted in accordance with standards or guidelines developed with input from appropriate health care providers and approved by a physician. The utilization review plan shall include the following components:
(1) Written procedures for:
(A) Notification of the utilization review
agent's determinations provided to the enrollee, a person acting on behalf of
the enrollee, or the enrollee's provider of record as addressed in section 5 of
this rule.
(B) Appeal of an adverse
determination and a copy of any forms used during the appeal process, as
required by section 6 of this rule.
(C) Receiving or redirecting toll free
telephone calls during normal business hours and after hour calls, either in
person or by recording, and assurance that a toll free number will be
maintained forty (40) hours per week during normal business hours as addressed
in section 7 of this rule.
(D)
Reviewing, including the following:
(i) Any
form used during the review process.
(ii) Time frames that shall be met during the
review.
(E) Handling of
written complaints by enrollees, patients, or health care providers, as
addressed in section 9(a) of this rule.
(F) Determining if health care providers
utilized by the utilization review agent are licensed.
(G) Orientation and training of personnel who
perform utilization review.
(H)
Assuring that patient-specific information obtained during the process of
utilization review, as addressed in section 8 of this rule, will be:
(i) kept confidential in accordance with
applicable federal and state laws;
(ii) used for purposes of utilization review,
quality assurance, discharge planning, and catastrophic case
management;
(iii) shared with only
those agencies (such as the claims administrator) that have authority to
receive such information; and
(iv)
summary data shall not be considered confidential if it does not provide
sufficient information to allow for identification of individual
patients.
(2)
Each utilization review agent shall utilize written screening criteria and
review procedures that are established and periodically evaluated and updated
with appropriate involvement from health care providers. Such written screening
criteria and review procedures shall be available for review and inspection by
the commissioner or a designated department of insurance representative and
copying, as necessary, for the commissioner to carry out his or her lawful
duties under the Insurance Code, provided; however, that any information
obtained or acquired under the authority of this rule and IC 27-8-17 is
confidential and privileged and not subject to the open records law or subpoena
except to the extent necessary for the commissioner to enforce this rule and IC
27-8-17.
(3) Utilization review
decisions shall be made in accordance with standards or guidelines that are
developed with input from appropriate health care providers and approved by a
physician.
Notes
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