Requirements of Utilization Review Program Documents

PURPOSE: This rule defines the contents of written utilization review program documents required of certain health carriers by section 376.1359, RSMo, H.B. 335 (First Regular Session of the 89th General Assembly 1997). (1) The written utilization review program document required of health carriers by section 376.1359.1, RSMo, H.B. 335 (First Regular Session of the 89th General Assembly 1997), for plans containing a managed care component shall describe— (A) Policies, processes and procedures which govern all aspects of the utilization review process, including but not limited to: 1. Scope and objectives; 2. Program organization; 3. Monitoring and oversight mechanisms; 4. Evaluation and organizational improvement of clinical review activities; and 5. Delegation of responsibility for utilization review activities; (B) Policies, processes and procedures to ensure that patient-specific information collected during the utilization review process— 1. Is kept confidentially in accordance with applicable federal and state laws; and 2. Is limited to that information necessary for utilization review of the services under review; (C) Policies, processes and procedures concerning utilization review decision criteria which— 1. Require the utilization review decision to be in writing; 2. Document the clinical utilization review criteria used; 3. Require utilization review criteria to be based on sound clinical evidence; 4. Provide for periodic evaluations of the utilization review decision criteria to assure ongoing efficacy; and 5. Coordinate the utilization review program with other medical management activities conducted by the health carrier, such as quality assurance, credentialing, provider contracting, data reporting, grievance procedures, processes for accessing member satisfaction and risk management; (D) Policies requiring the medical director administering the program to be a qualified health care professional licensed in the state of Missouri; (E) The utilization review decision-making policies, processes, and procedures including, but not limited to, those that ensure: 1. Decisions are made in a timely manner as required by sections 376.1363, 376.1365 and 376.1367, RSMo, H.B. 335 (First Regular Session of the 89th General Assembly 1997); 2. The health carrier obtains all information required to make utilization review decisions, including pertinent clinical information; 3. Utilization reviewers apply clinical review criteria consistently; 4. Adverse determinations are evaluated by a clinical peer, licensed in any state, as to appropriateness, either before or after the determination is made; 5. Timely access to review staff is provided to enrollees and providers by means of a toll-free number; 6. Enrollees or providers on behalf of enrollees may appeal for coverage of medically necessary pharmaceutical prescriptions and durable medical equipment as part of the process; and 7. Compliance with section 376.1367, RSMo, H.B. 335 (First Regular Session of the 89th General Assembly 1997), concerning emergency services; (F) The data systems used in utilization review program activities and the manner in which the health carrier measures the system’s ability to generate management reports to enable the health carrier to monitor and manage health care services effectively; (G) All policies, processes and procedures whereby the health carrier maintains oversight of utilization review activities delegated to a utilization review organization, including: 1. Those ensuring that appropriate personnel have operational responsibility for the conduct of the utilization review program; 2. Those ensuring the utilization review organization complies with sections 376.1350 to 376.1390, RSMo, H.B. 335 (First Regular Session of the 89th General Assembly 1997); 3. A description of the utilization review organization’s activities and responsibilities, including reporting requirements; and 4. Those by which the health carrier evaluates the performance of the utilization review organization; (H) All processes and procedures for making, reconsidering and appealing utilization review determinations; (I) All processes and procedures for notifying enrollees and providers acting on behalf of the enrollees, and any other party entitled to notice, of— 1. The health carrier’s determinations; 2. Instructions for initiating an appeal or reconsideration; and 3. Instructions for requesting a written statement of the clinical rationale, including the review criteria, used to make the determination; and (J) All policies and procedures addressing the failure or inability of a provider or an enrollee to provide all necessary information for review. (2) A health carrier may satisfy the requirements of section (1) by implementing the most recent utilization review program document it has submitted to either the Utilization Review Accreditation Commission (URAC) or the National Committee for Quality Assurance (NCQA) for certification, or to any similar entity, but only if— (A) The utilization review program document submitted for accreditation is supplemented to include the information required by section (1); and (B) The utilization review program document reflects current policies, processes and procedures which the health carrier applies to the plan. AUTHORITY: sections 374.045 and 376.1359, RSMo Supp. 1997.* Original rule filed Nov. 3, 1997, effective June 30, 1998. *Original authority: 374.045, RSMo 1967, amended 1993, 1995 and 376.1359, RSMo 1997.