(A) No private review agent may conduct utilization reviews in this State unless the director or his designee has granted the private review agent a certificate to perform these activities. The director or his designee, in his discretion, may approve or deny certificate applications.
(B) An applicant for a certificate shall pay the director or his designee the application fee as provided in Section 38-70-50 and shall submit an application to the director or his designee on forms and with any supporting documentation that the director or his designee requires. The application must contain information regarding the utilization review programs to be conducted by the applicant which must meet the requirements contained in subsection (C).
(C) A utilization review program of the applicant must meet the following minimum standards:
(1) notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within five business days;
(2) all utilization review agents shall maintain a procedure by which insured or providers may seek reconsideration of appeal of determinations of the utilization review agent;
(3) a representative of the utilization review agent must be accessible by telephone to insureds or providers in South Carolina, at least forty hours each week during normal business hours;
(4) the type and qualification of the personnel either employed or under contract to perform the utilization reviews must be included in the utilization review program information submitted to the director or his designee;
(5) a copy of the materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan must be provided interested parties upon request; and
(6) an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed.
HISTORY: 1990 Act No. 311, Section 2; 1993 Act No. 181, Section 746.
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