§ 27-18.9-5. Administrative and non-administrative benefit determination procedural requirements. (a) Procedural failure by claimant.

(1) In the event of the failure of claimant or an authorized representative to follow the health care entities claims procedures for a pre-service claim the health care entity or its review agent must:

(i) Notify claimant or the authorized representative, as appropriate, of this failure as soon as possible and no later than five (5) calendar days following the failure and this notification must also inform claimant of the proper procedures to file a pre-service claim; and

(ii) Notwithstanding the above, if the pre-service claim relates to urgent or emergent health care services, the health care entity or its review agent must notify and inform claimant or the authorized representative, as appropriate, of the failure and proper procedures within twenty-four (24) hours following the failure. Notification may be oral, unless written notification is requested by the claimant or authorized representative.

(2) Claimant must have stated name, specific medical condition or symptom and specific treatment, service, or product for which approval is requested and submitted to proper claim processing unit.

(b) Utilization review agent procedural requirements:

(1) All initial, prospective, and concurrent non-administrative, adverse benefit determinations of a health care service that had been ordered by a physician, dentist, or other practitioner shall be made, documented, and signed by a licensed practitioner with the same licensure status as the ordering provider;

(2) Utilization review agents are not prohibited from allowing appropriately qualified review agency staff from engaging in discussions with the attending provider, the attending provider's designee or appropriate health care facility and office personnel regarding alternative service and/or treatment options. Such a discussion shall not constitute an adverse benefit determination; provided, however, that any change to the attending provider's original order and/or any decision for an alternative level of care must be made and/or appropriately consented to by the attending provider or the provider's designee responsible for treating the beneficiary and must be documented by the review agent; and

(3) A utilization review agent shall not retrospectively deny authorization for health care services provided to a covered person when an authorization has been obtained for that service from the review agent unless the approval was based upon inaccurate information material to the review or the health care services were not provided consistent with the provider's submitted plan of care and/or any restrictions included in the prior approval granted by the review agent.

History of Section. (P.L. 2017, ch. 302, art. 5, § 5.)