Utilization review and quality assurance

The organization has instituted a program of utilization review and quality assurance to monitor and control the use of health care services. The organization shall develop and identify the mode and manner of submissions for utilization review and quality assurance requests. 1. Prior authorization for services must be obtained from the organization or its managed care vendor at least seventy-two hours or three business days in advance of providing certain medical treatment, equipment, or supplies. Medical services requiring prior authorization or preservice review are outlined in section 92-01-02-34. Emergency medical services may be provided without prior authorization, but notification is required within twenty-four hours of, or by the end of the next business day following, initiation of emergency treatment. Reimbursement may be withheld, or recovery of prior payments made, if utilization review does not confirm the medical necessity of emergency medical services. 2. Documentation of the need for and efficacy of continued medical care by the allied health care professional is required at the direction or request of the organization or the managed care vendor while a claim is open. 3. The organization may require second opinion consultations prior to the authorization of reimbursement for surgery and for conservative care which extends past sixty days following the initial visit. 4. The organization may require preoperative psychosocial screens and psychological evaluations prior to the authorization of reimbursement for surgery. The organization may select the evaluators who will perform the screens and evaluations. 5. The organization may use the Official Disability Guidelines, the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, Guide to Physical Therapy Practice, The Medical Disability Advisor, Diagnosis and Treatment for Physicians and Therapists Upper Extremity Rehabilitation, Treatment Guidelines of the American Society of Hand Therapists, American Medical Association Guides to the Evaluation of Disease and Injury Causation, or any other treatment and disability guidelines or standards it deems appropriate to administer claims.