In conjunction with an application for a certificate, the private review agent shall submit information that the Insurance Commissioner requires, including, but not limited to:

1. A utilization review plan that includes:

a.an adequate summary description of review standards, protocol and procedures to be used in evaluating proposed or delivered hospital and medical care,

b.assurances that the standards and criteria to be applied in review determinations are established with input from health care providers representing major areas of specialty and certified by the boards of the various American medical specialties. The entity shall provide the Commissioner with a list of such representatives and their major areas of specialty upon request, and

c.the provisions by which patients or health care providers may seek reconsideration or appeal of adverse decisions by the private review agent;

2. The type and qualifications of the personnel either employed or under contract to perform the utilization review;

3. The procedures and policies to ensure that a representative of the private review agent is reasonably accessible, if domiciled in this state, to patients and health care providers five (5) days a week during normal business hours, such procedures and policies to include as a requirement a toll-free telephone number to be available during said business hours; provided, in the alternative, the out-of-state private review agent shall be available or make staff available by toll-free telephone for at least forty (40) hours per week during normal business hours and shall have a telephone system which is capable of accepting or recording incoming telephone calls during other than normal hours, and shall respond to such calls within two (2) working days, if sufficient information is provided to whomever accepts the call or on a recorded message;

4. The policies and procedures to ensure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed;

5. The policies and procedures to verify the identity and authority of personnel performing utilization review by telephone;

6. A copy of the materials designed to inform applicable patients and health care providers of the requirements of the utilization review plan;

7. A list of the third party payors for which the private review agent is performing utilization review in this state. Said list may be deemed confidential by the Commissioner for the purpose of protecting competition between agents;

8. The procedures for receiving and handling complaints by patients and health care providers concerning utilization review; and

9. Procedures to ensure that after a request for medical evaluation, treatment, or procedures has been rejected in whole or in part and in the event a copy of the report on said rejection is requested, a copy of the report of a private review agent concerning the rejection shall be mailed by the insurer, postage prepaid, to the ill or injured person, the treating health care provider or to the person financially responsible for the patient's bill within fifteen (15) days after receipt of the request for the report.

Added by Laws 1991, c. 294, § 8, eff. Nov. 1, 1991.