N.D.C.C. Chapter 26.1-26.4 - Regulation of Utilization Review Agents

[LOGO] EARL R. POMEROY COMMISSIONER OF INSURANCE State of North Dakota DEPARTMENT OF INSURANCE Fifth Floor State Capitol Bismarck, North Dakota 58505 Telephone (701) 224-2440 Consumer "HOTLINE" 1-800-247-0560 # BULLETIN 92-1 TO: ALL COMPANIES WRITING ACCIDENT AND HEALTH INSURANCE FROM: Earl R. Pomeroy, Commissioner DATE: January 15, 1992 SUBJECT: N.D.C.C. Chapter 26.1-26.4 - Regulation of Utilization Review Agents The 1991 session of the North Dakota Legislative Assembly enacted N.D.C.C. Chapter 26.1-26.4 dealing with the regulation of utilization review agents. This chapter establishes minimum standards and requires utilization review agents to certify their compliance in a filing to the Commissioner of Insurance. This requirement applies to any person or entity performing utilization review except an agency of the federal government or to activities performed by an entity acting on behalf of the federal government. Forms are enclosed to assist you in the completion of filing and certification responsibilities you may have under this chapter. ERP/njb Enclosures # UTILIZATION REVIEW FILING REPORT NORTH DAKOTA INSURANCE DEPARTMENT SFN 18332 (11-91) | N.D.C.C. Chapter 26.1-26.4 | | | Filing Date | | | --- | --- | --- | --- | --- | | Full Name of Organization | | | | | | Other Names Organization Has Been Known By or Is DBA | | | | | | Business Address | | City | State | Zip Code | | Telephone Number | Business Hours | State in Which Organized | Date Organized | | | Contact Person | | | Telephone Number | | # INCLUDE WITH FILING: 1. A description of the appeal procedures for utilization review determinations. 2. Utilization Review Agent Certification (Attached). 3. Ten dollar (\$10.00) filing fee pursuant to N.D.C.C. 26.1-01-07(21). State of _______________ ) )ss. County of _______________ ) ours | State in Which Organized | Date Organized | | | Contact Person | | | Telephone Number | | # INCLUDE WITH FILING: 1. A description of the appeal procedures for utilization review determinations. 2. Utilization Review Agent Certification (Attached). 3. Ten dollar (\$10.00) filing fee pursuant to N.D.C.C. 26.1-01-07(21). State of _______________ ) )ss. County of _______________ ) The undersigned authorized representative, being first duly sworn, deposes and says that he/she has executed the foregoing filing; that he/she has read the said filing and knows the contents thereof and attached thereto; that to the best of his/her knowledge and belief the statements made in the said filing and in any rider attached thereto are true and correct and are complete in every material respect and do not contain any statement which, under the circumstances under which it is made, would be false or would tend to be misleading in respect to any material fact; and that he/she has read and understands the insurance laws of the State of North Dakota. Subscribed and sworn to before me this __________ day of _______________, 19____. Organization (SEAL) Authorized Representative Office Notary Public My Commission Expires _______________ [LOGO] UTILIZATION REVIEW AGENT CERTIFICATION NORTH DAKOTA INSURANCE DEPARTMENT SFN 18378 (12-91) N.D.C.C. Chapter 26.1-26.4 TO THE COMMISSIONER OF INSURANCE OF THE STATE OF NORTH DAKOTA: | Name of Organization | | | | | --- | --- | --- | --- | | Address | City | State | Zip Code | # CERTIFIES COMPLIANCE WITH THE FOLLOWING: N.D.C.C. 26.1-26.4-04. Minimum standards of utilization review agents. All utilization review agents must meet the following minimum standards: 18378 (12-91) N.D.C.C. Chapter 26.1-26.4 TO THE COMMISSIONER OF INSURANCE OF THE STATE OF NORTH DAKOTA: | Name of Organization | | | | | --- | --- | --- | --- | | Address | City | State | Zip Code | # CERTIFIES COMPLIANCE WITH THE FOLLOWING: N.D.C.C. 26.1-26.4-04. Minimum standards of utilization review agents. All utilization review agents must meet the following minimum standards: 1. Notification of a determination by the utilization review agent must be mailed or otherwise communicated to the provider of record or the enrollee or other appropriate individual within two business days of the receipt of the request for determination and the receipt of all information necessary to complete the review. 2. Any determination by a utilization review agent as to the necessity or appropriateness of an admission service, or procedure must be reviewed by a physician or, if appropriate, a licensed psychologist, or determined in accordance with standards or guidelines approved by a physician or licensed psychologist. 3. Any notification of a determination not to certify an admission or service or procedure must include the principal reason for the determination and the procedures to initiate an appeal of the determination. 4. Utilization review agents shall maintain and make available a written description of the appeal procedure by which enrollees or the provider of record may seek review of determinations by the utilization review agent. The appeal procedure must provide for the following: ocedure must include the principal reason for the determination and the procedures to initiate an appeal of the determination. 4. Utilization review agents shall maintain and make available a written description of the appeal procedure by which enrollees or the provider of record may seek review of determinations by the utilization review agent. The appeal procedure must provide for the following: a. On appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate must be made by a physician or, if appropriate, a licensed psychologist. b. Utilization review agents shall complete the adjudication of appeals of determinations not to certify admissions, services, and procedures no later than thirty days from the date the appeal is filed and the receipt of all information necessary to complete the appeal. c. Utilization review agents shall provide for an expedited appeals process for emergency or life-threatening situations. Utilization review agents shall complete the adjudication of expedited appeals within forty-eight hours of the date the appeal is filed and the receipt of all information necessary to complete the appeal. 5. Utilization review agents shall make staff available by toll-free telephone at least forty hours per week during normal business hours. 6. Utilization review agents shall have a telephone system capable of accepting or recording incoming telephone calls during other than normal business hours and shall respond to these calls within two working days. 7. Utilization review agents shall comply with all applicable laws to protect confidentiality of individual medical records. 8. Physicians or psychologists making utilization review determinations shall have current licenses from a state licensing agency in the United States. 9 ncoming telephone calls during other than normal business hours and shall respond to these calls within two working days. 7. Utilization review agents shall comply with all applicable laws to protect confidentiality of individual medical records. 8. Physicians or psychologists making utilization review determinations shall have current licenses from a state licensing agency in the United States. 9. Utilization review agents shall allow a minimum of twenty-four hours following an emergency admission, service, or procedure for an enrollee or the enrollee's representative to notify the utilization review agent and request certification or continuing treatment for that condition. However, the commissioner may find that the standards in this section have been met if the utilization review agent has received approval or accreditation by a utilization review accreditation organization. SFN 18378 (12-91) Page 2 State of ________________________ ) )ss. County of ________________________ ) The undersigned authorized representative, being first duly sworn, deposes and says that he/she has executed the foregoing certification; that he/she has read the said certification and knows the contents thereof; that to the best of his/her knowledge and belief the named organization is in full compliance with the minimum standards of utilization review agents required by the laws of North Dakota; and does hereby officially certify compliance with N.D.C.C. 26.1-26.4-04 and all applicable insurance laws of the State of North Dakota. Subscribed and sworn to before me this ________________________ day of ________________________ 19 ______. (Organization) ( SEAL ) (Authorized Representative) (Office) (Notary Public) My Commission Expires ________________________