33-32-207. Health insurance issuer duties for utilization review. (1) A health insurance issuer that requires a request for benefits under the covered person's health plan to be subjected to utilization review shall implement a utilization review program with written documentation describing all review activities and procedures, both delegated and nondelegated, for:

(a) the filing of benefit requests;

(b) the notification of utilization review and benefit determinations; and

(c) the review of adverse determinations in accordance with Title 33, chapter 32, parts 3 and 4.

(2) The written documentation must describe the following:

(a) procedures to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services;

(b) data sources and clinical review criteria used in decisionmaking;

(c) mechanisms to ensure consistent application of clinical review criteria and compatible decisions;

(d) data collection processes and analytical methods used in assessing utilization of health care services;

(e) provisions for ensuring confidentiality of clinical and proprietary information;

(f) the organizational structure that periodically assesses utilization review activities and reports to the health insurance issuer's governing body. This organizational structure may include but is not limited to the utilization review committee or a quality assurance committee.

(g) the staff position functionally responsible for day-to-day program management.

(3) A health insurance issuer shall:

(a) file an annual summary report of its utilization review program activities with the commissioner in the format specified by the commissioner;

(b) maintain records for a minimum of 6 years of all benefit requests, claims, and notices associated with utilization review and benefit determinations made in accordance with 33-32-211 and 33-32-212; and

(c) make the records maintained under subsection (3)(b) available, on request, for examination by covered persons, the commissioner, and appropriate federal agencies.

History: En. Sec. 3, Ch. 428, L. 2015.