Electronic Confirmation of Utilization Review Determinations Deemed Made When

PURPOSE: This rule describes the conditions under which an electronic notice of a utilization review determination will be deemed to have been made. (1) When a health carrier is required by section 376.1363, RSMo, H.B. 335 (First Regular Session of the 89th General Assembly 1997), to provide written or electronic confirmation of its utilization review determinations to providers, enrollees or certificate holders (enrollees and certificate holders hereinafter collectively referred to as enrollees), for plans containing a managed care component, an electronic confirmation will be deemed by the department to have been made if the confirmation is available to the provider and enrollee on an interactive voice response telephone system or other electronic notification system which is universally accessible and compatible with the Telecommunication Device for the Deaf, if— (A) The system has a security component to prevent enrollees’ confidential information from being accessed by unauthorized individuals; and (B) The confirmation can be accessed by the enrollee and the enrollee’s provider for a minimum of sixty (60) days after the determination is made; and (C) Written confirmation of the determination may be requested by the enrollee or provider by means of the system; and (D) All requests made by enrollees and providers for written confirmation are honored within the time limits imposed by section 376.1363, 376.1365 or 376.1367, RSMo Supp. 1997; and (E) The system may be accessed by enrollees and providers by means of a tollfree number; and (F) All determinations and notifications are archived by the health carrier for a period of three (3) years after the determinations are made. AUTHORITY: section 374.045.1, RSMo Supp. 1997.* Original rule filed Nov. 3, 1997, effective June 30, 1998. *Original authority: 374.045, RSMo 1967, amended 1993, 1995.