44-5422. Utilization review agents; procedures applicable; exceptions.

(1) Utilization review agents operating in this state shall comply with the following provisions:

(a) A utilization review agent, employees of a utilization review agent, or persons acting on behalf of a utilization review agent may not refer a patient who has undergone utilization review by that utilization review agent, employee, or person to:

(i) A health care facility or other provider in which the utilization review agent owns a significant beneficial interest; or

(ii) The utilization review agent's own health care practice;

(b) A utilization review agent, employees of a utilization review agent, or persons acting on behalf of a utilization review agent shall not accept or agree to accept any sum from any person for bringing or referring a patient to a health care provider;

(c) A utilization review agent shall not compensate employees or persons acting on behalf of the utilization review agent based directly on the number of adverse determinations;

(d) A utilization review agent shall allow a minimum of twenty-four hours following an emergency admission, service, or procedure for a covered person or his or her representative to notify the utilization review agent and request certification or continuing treatment for the condition;

(e) A covered person or an attending physician on behalf of a covered person may request an appeal of a decision not to approve or certify for clinical reasons. For such appeal, a covered person or attending physician on behalf of a covered person shall, upon request, have timely access to the clinical basis for the decision, including any criteria, standards, or clinical indicators used as a basis for such recommendation or decision;

(f) During a final appeal of a decision not to certify or approve for clinical reasons, a utilization review agent shall assure that a physician is reasonably available to review the case, except that if the health care services were provided or authorized by a provider other than a physician, such appeal may be reviewed by a nonphysician provider whose scope of practice includes the treatment or services. Hospitals, health care providers, or representatives of the covered person may assist in an appeal; and

(g) A utilization review agent shall comply with the standards adopted by the organization that has granted the agent approval or accreditation and upon which the certificate was granted by the director, whether or not action is taken by such organization to enforce the standards.

(2) Subdivisions (1)(a) and (b) of this section shall not apply to a utilization review agent, employees of the utilization review agent, or other persons acting on behalf of such utilization review agent who refer a patient to:

(a) The health care provider or facility that participates in a health maintenance organization in which the patient is enrolled; or

(b) A preferred provider network of participating providers or facilities to which the patient would otherwise be referred as part of the patient's insurance contract or policy.

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