45:14B-34. Review procedure

Within 10 days of the receipt of the request for review by a third-party payor, the treating psychologist shall notify the State Board of Psychological Examiners of the request. Pursuant to the provisions of section 14 of this act, the State Board of Psychological Examiners shall, within 10 days of the notification, inform the treating psychologist of two or more members of the independent professional review committee who shall be known as "reviewers" and who shall conduct the review. Under these circumstances, the patient may, pursuant to a valid authorization as described in section 6 of this act, authorize the treating psychologist to disclose to the reviewers the requested confidential information concerning his treatment. This information shall be disclosed only in accordance with the following procedure described in this section and shall not be disclosed to a third-party payor or any person other than the reviewers and shall not contain any reference to the patient's identification but rather shall refer to an identification number assigned by the third-party payor. If the patient gives a valid written authorization, the reviewers shall, pursuant to the following review procedure and within 20 days from their receipt of the review request from the State Board of Psychological Examiners, certify in writing to the third-party payor whether or not in their opinion the treatment in question is usual, customary or reasonable or if they are unable to make that determination. The treatment review shall take place as follows:

a. The treating psychologist shall provide in writing to the reviewers the following information: the case identification number; the status of the patient; duration and frequency of treatment; the diagnosis; the prognosis; and the level of functioning and the level of distress, both described by the terms mild, moderate, severe or extreme. If on the basis of this information the reviewers can certify that the treatment is usual, customary or reasonable, no further review shall be necessary at that time.

b. If the reviewers cannot make this determination from the information provided, the reviewers shall request the treating psychologist to provide a written statement describing his customary mode of treatment for the particular diagnosis given. If, on the basis of this information, the reviewers can certify that the treatment is usual, customary or reasonable, no further review shall be conducted at that time.

c. If the reviewers cannot make this determination from the information provided, they shall request the treating psychologist to provide details and circumstances concerning the case under review. The reviewers shall then certify to the third-party payor their conclusion as to whether or not the treatment in question is usual, customary or reasonable, and the date and length of time of the consultation.

d. A negative conclusion by the reviewers pursuant to this section shall not be used retroactively as a basis for denying benefits for the treatment furnished prior to the review request by the third-party payor, unless the claim for reimbursement involves fraud or was not filed in a timely manner.

L. 1985, c. 256, s. 4.