20 CSR 400-10.020 - Annual Reporting Requirements for Health Carriers Regarding Utilization Review Activities

PURPOSE: This rule sets forth the reporting requirements of health carriers, pursuant to sections 376.1359, 376.1369 and 376.1378, RSMo, found in H.B. 335, 1997, regarding utilization review activities.

(1) All health carriers which market health care plans which have a managed care component shall make the following report regarding utilization review activities to the director, annually, on or before March 1:

(A) Where the health carrier is acting as a utilization review agent, the health carrier shall file a report of its utilization review activities, which report shall include a summary of the types of utilization review activities and any other information the director may require;

(B) Where the health carrier has contracted with an outside utilization review organization, or otherwise delegated its utilization review activities, the health carrier shall file a report of the utilization review activities, which report shall include a summary of the types of utilization review activities and a list of the entities or organizations conducting the utilization review activities, including the address of the utilization review agent or organization used; and

(C) The director may allow a health carrier to file, in lieu of the report otherwise required, a copy of a health carrier's report to another agency, provided such report contains the information required by this rule.

(2) All health carriers shall include in the report required by section (1) of this rule, a written certification, pursuant to section 376.1369, RSMo, H.B. 335, 1997, that the utilization review program of the health carrier or its designee complies with all applicable state and federal laws that establish confidentiality and reporting requirements.

(3) All health carriers or its designee shall include in the report required by section (1) of this rule a copy of the grievance procedures and all forms for the processing of grievances used by the health carrier or its designee. Where these documents are already on file with the director, the health carrier shall file, as a part of the report required by section (1) of this rule, all material modifications made to the grievance procedures or forms.

(4) All health carriers or its designee as a part of the report required by section (1) of this rule, shall file a written certification of compliance, pursuant to section 376.1378, RSMo, H.B. 335, 1997, stating that the health carrier or its designee has established and maintained, for each of its benefit plans, grievance procedures that fully comply with the provisions of sections 376.1350 to 376.1390, RSMo, H.B. 335, 1997.

Notes

20 CSR 400-10.020

AUTHORITY: sections 354.485, 374.045 and 374.515, RSMo 1994 and 376.1359, 376.1369, 376.1378 and 376.1399, RSMo Supp. 1997.* Original rule filed Nov. 3, 1997, effective May 30, 1998.

*Original authority: 354.485, RSMo 1983; 374.045, RSMo 1967, amended 1993; 374.515, RSMo 1991, amended 1993; 376.1359, 376.1369 and 376.1378, RSMo 1997; and 376.1399, RSMo 1997, amended 1997.