Utilization Review

PURPOSE: This rule sets forth the procedure for a utilization review agent to obtain and maintain a certificate of registration and establishes fees and forms pursuant to the requirements of section 374.505, RSMo. The rule also clarifies the standards applicable to utilization review agents conducting utilization review in this state. (1) Pursuant to the requirements of section 374.505, RSMo, each application for a certificate of registration as a utilization review agent shall— (A) Be submitted to the department on a form provided by the department; (B) Be signed by the applicant or, if the applicant is a corporation, by an officer or, if the applicant is a partnership, by one (1) of the partners; (C) Be accompanied by an initial registration fee of one thousand dollars ($1,000); (D) Disclose all fictitious names under which the applicant entity will operate as a utilization review agent in this state; and (E) Provide any other reasonably related supporting documentation necessary to process the utilization review agent’s registration. (2) Each recipient of a certificate of registration may maintain their registration by filing for renewal annually on or before the anniversary date of the initial certificate as shown on the original certification. Each application for renewal shall— (A) Be submitted on a form provided by the department; (B) Be accompanied by a renewal fee of five hundred dollars ($500); (C) Be accompanied by a list of the utilization review agent’s current health plan clients with contact information for each such health plan client. A list of the health plan’s clients is not necessary; (D) Disclose all fictitious names under which the applicant entity has and will operate as a utilization review agent in this state; and (E) Provide any other reasonably related supporting documentation necessary to maintain the utilization review agent’s registration. (3) Failure to renew a certificate of registration may result in a fine as set forth in section 374.280, RSMo. (4) Pursuant to sections 374.046 and 374.512, RSMo, the director may take action against any utilization review agent doing business in this state without a certificate of registration in violation of section 374.503, RSMo, even if the principal place of business of the utilization review agent is located in another state. (5) Any utilization review agent doing business in this state under a name other than its true name shall file with the director a copy of all documents, including the authorization from the Missouri Secretary of State which shows the legal authority for the utilization review agent to use such other name. (6) Pursuant to section 374.510, RSMo, the minimum requirements of sections 376.1350 to 376.1399, RSMo, as applied to utilization review agents include, but are not limited to, the following: (A) That any medical director who administers the utilization review program or oversees the review decisions be a qualified health care professional licensed in the state of Missouri; (B) That a licensed clinical peer evaluate the clinical appropriateness of adverse determinations; (C) That utilization review decisions be made and issued in a timely manner pursuant to the requirements of sections 376.1363, 376.1365, and 376.1367, RSMo; (D) That a utilization review agent provide health plan enrollees and health plan participating providers with timely access to its review staff by a toll-free number; (E) That when conducting utilization review, the utilization review agent shall collect only the information necessary to certify the admission, procedure or treatment, length of stay, frequency, and duration of services and not require or request a Federal Drug Enforcement Administration Number or a Missouri Controlled Substance Registration Number from any provider; (F) That compensation to persons providing utilization review services for a utilization review agent not contain direct or indirect incentives for such persons to make medically inappropriate review decisions or be directly or indirectly based on the quantity or type of adverse determinations rendered; (G) That a utilization review agent responsible for pre-approving any covered benefits or services issue a confirmation number to the enrollee when it authorizes the provision of health care services; and (H) That if a utilization review agent authorizes the provision of health care services, the utilization review agent not subsequently retract its authorization after the health care services have been provided, or reduce payment for an item or service furnished in reliance on approval, unless— 1. Such authorization is based on a material misrepresentation or omission about the treated person’s health condition or the cause of the health condition; or 2. The health benefit plan terminates before the health care services are provided; or 3. The covered person’s coverage under the health benefit plan terminates before the health care services are provided. (7) The following form has been adopted and approved for filing with the department: (A) Utilization Review Agent Application for Certificate of Registration (“Form UR1”), or any form which substantially comports with the specified form. (8) The department on request will supply in printed format the forms listed in this rule. Accurate reproduction of the forms may be utilized for filing in lieu of the printed forms. All application forms referenced herein are available at http://www.insurance.mo.gov. AUTHORITY: sections 374.515 and 376.1399, RSMo 2016.* Emergency rule filed Nov. 1, 1991, effective Nov. 11, 1991, expired March 10, 1992. Original rule filed Nov. 1, 1991, effective May 14, 1992. Amended: Filed Aug. 26, 1993, effective May 9, 1994. Amended: Filed Nov. 3, 1997, effective May 30, 1998. Amended: Filed April 23, 1999, effective Nov. 30, 1999. Amended: Filed March 28, 2007, effective Oct. 30, 2007. Amended: Filed Dec. 3, 2007, effective July 30, 2008. Amended: Filed June 4, 2020, effective Jan. 30, 2021. *Original authority 374.515, RSMo 1991, amended 1993 and 376.1399, RSMo 1997, amended 1997, 2007.