Bill not drafted by TLC or Senate E&E.
Line and page numbers may not match official copy.
By Smithee H.B. No. 1100
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to utilization review under health benefit plans and
1-3 health insurance policies.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 2, Article 21.58A, Insurance Code, is
1-6 amended to read as follows:
1-7 Sec. 2. DEFINITIONS. In this article:
1-8 (1) "Administrative procedure act" means Chapter 2001,
1-9 Government Code [the Administrative Procedure and Texas Register
1-10 Act (Article 6252-13a, Vernon's Texas Civil Statutes)].
1-11 (2) "Administrator" means a person holding a
1-12 certificate of authority under Article 21.07-6 of this code.
1-13 (3) "Adverse determination" means a determination by a
1-14 utilization review agent that the health care services furnished or
1-15 proposed to be furnished to a patient are not medically necessary
1-16 or not appropriate in the allocation of health care resources.
1-17 (4) ["Board" means the State Board of Insurance.]
1-18 [(5)] "Certificate" means a certificate of
1-19 registration granted by the commissioner [board] to a utilization
1-20 review agent.
1-21 (5) [(6)] "Commissioner" means the commissioner of
1-22 insurance.
1-23 (6) [(7)] "Emergency care" means health care services
1-24 provided in a hospital emergency facility to evaluate and treat
2-1 medical conditions of a recent onset and severity, including but
2-2 not limited to severe pain that would lead a prudent layperson
2-3 possessing an average knowledge of medicine and health to believe
2-4 that his or her condition, sickness, or injury is of such a nature
2-5 that failure to get immediate medical care could result in:
2-6 (A) placing the patient's health in serious
2-7 jeopardy;
2-8 (B) serious impairment to bodily functions;
2-9 (C) serious dysfunction of any bodily organ or
2-10 part;
2-11 (D) serious disfigurement; or
2-12 (E) in the case of a pregnant woman, serious
2-13 jeopardy to the health of the fetus [bona fide emergency services
2-14 as defined in Section 2(I), Chapter 397, Acts of the 54th
2-15 Legislature, 1955 (Article 3.70-2, Vernon's Texas Insurance Code)
2-16 and Section 2(t), Texas Health Maintenance Organization Act
2-17 (Article 20A.02, Vernon's Texas Insurance Code)].
2-18 (7) [(8)] "Dental plan" means an insurance policy or
2-19 health benefit plan, including a policy written by a company
2-20 subject to Chapter 20 of this code, that provides coverage for
2-21 expenses for dental services.
2-22 (8) [(9)] "Enrollee" means a person covered by a
2-23 health insurance policy or plan and includes a person who is
2-24 covered as an eligible dependent of another person.
2-25 (9) [(10)] "Health benefit plan" means a plan of
2-26 benefits that defines the coverage provisions for health care for
2-27 enrollees offered or provided by any organization, public or
2-28 private, other than health insurance.
2-29 (10) [(11)] "Health care provider" means any person,
2-30 corporation, facility, or institution licensed by a state to
3-1 provide or otherwise lawfully providing health care services that
3-2 is eligible for independent reimbursement for those services.
3-3 (11) [(12)] "Health insurance policy" means an
3-4 insurance policy, including a policy written by a company subject
3-5 to Chapter 20 of this code, that provides coverage for medical or
3-6 surgical expenses incurred as a result of accident or sickness.
3-7 (12) [(13)] "Nurse" means a professional or registered
3-8 nurse, a licensed vocational nurse, or a licensed practical nurse.
3-9 (13) [(14)] "Open meetings law" means Chapter 551,
3-10 Government Code [271, Acts of the 60th Legislature, Regular
3-11 Session, 1967 (Article 6252-17, Vernon's Texas Civil Statutes)].
3-12 (14) [(15)] "Open records law" means Chapter 552,
3-13 Government Code [424, Acts of the 63rd Legislature, Regular
3-14 Session, 1973 (Article 6252-17a, Vernon's Texas Civil Statutes)].
3-15 (15) [(16)] "Patient" means the enrollee or an
3-16 eligible dependent of the enrollee under a health benefit plan or
3-17 health insurance plan.
3-18 (16) [(17)] "Payor" means:
3-19 (A) an insurer writing health insurance
3-20 policies;
3-21 (B) any preferred provider organization, health
3-22 maintenance organization, self-insurance plan; or
3-23 (C) any other person or entity which provides,
3-24 offers to provide, or administers hospital, outpatient, medical, or
3-25 other health benefits to persons treated by a health care provider
3-26 in this state pursuant to any policy, plan, or contract.
3-27 (17) [(18)] "Physician" means a licensed doctor of
3-28 medicine or a doctor of osteopathy.
3-29 (18) [(19)] "Provider of record" means the physician
3-30 or other health care provider that has primary responsibility for
4-1 the care, treatment, and services rendered to the enrollee and
4-2 includes any health care facility when treatment is rendered on an
4-3 inpatient or outpatient basis.
4-4 (19) [(20)] "Utilization review" means a system for
4-5 prospective or concurrent review of the medical necessity and
4-6 appropriateness of health care services being provided or proposed
4-7 to be provided to an individual within this state. Utilization
4-8 review shall not include elective requests for clarification of
4-9 coverage.
4-10 (20) [(21)] "Utilization review agent" means an entity
4-11 that conducts utilization review for:
4-12 (A) an employer with employees in this state who
4-13 are covered under a health benefit plan or health insurance policy;
4-14 (B) a payor; or
4-15 (C) an administrator.
4-16 (21) [(22)] "Utilization review plan" means the
4-17 screening criteria and utilization review procedures of a
4-18 utilization review agent.
4-19 (22) [(23)] "Working day" means a weekday, excluding a
4-20 legal holiday.
4-21 SECTION 2. Subsections (b), (d), (e), and (f), Section 3,
4-22 Article 21.58A, Insurance Code, are amended to read as follows:
4-23 (b) The commissioner may only issue a certificate to an
4-24 applicant that has met all the requirements of this article and all
4-25 applicable rules and regulations of the commissioner [board].
4-26 (d) Certification may be renewed biennially by filing, not
4-27 later than March 1, a renewal form with the commissioner
4-28 accompanied by a renewal fee in an amount set by the commissioner
4-29 [board].
4-30 (e) The commissioner shall promulgate certification and
5-1 renewal forms to be filed under this section. The form for initial
5-2 certification must require the following:
5-3 (1) the entity's name, address, telephone number, and
5-4 normal business hours;
5-5 (2) the name and address of an agent for service of
5-6 process in this state;
5-7 (3) a summary of the utilization review plan, but in
5-8 no event shall proprietary details be subject to inclusion in the
5-9 summary;
5-10 (4) information concerning the personnel categories
5-11 that will perform utilization review for the utilization review
5-12 agent;
5-13 (5) a copy of the procedure established by the
5-14 utilization review agent as required by this article for appeal of
5-15 an adverse determination;
5-16 (6) a certification that the utilization review agent
5-17 will comply with the provisions of this article; and
5-18 (7) a copy of the procedures for handling oral and
5-19 written complaints by enrollees, patients, or health care
5-20 providers.
5-21 (f) The commissioner [board] shall establish, administer,
5-22 and enforce the certification and renewal fees under this section
5-23 in amounts not greater than that necessary to cover the cost of
5-24 administration of this article.
5-25 SECTION 3. Subsections (c), (h), (i), (k), (m), and (n),
5-26 Section 4, Article 21.58A, Insurance Code, are amended to read as
5-27 follows:
5-28 (c) Personnel employed by or under contract with the
5-29 utilization review agent to perform utilization review shall be
5-30 appropriately trained and qualified. Personnel who obtain
6-1 information directly from the physician or health care provider,
6-2 either orally or in writing, and who are not physicians shall be
6-3 nurses or[,] physician assistants, [registered records
6-4 administrators, or accredited records technicians,] who are either
6-5 licensed or certified[, or shall be individuals who have received
6-6 formal orientation and training in accordance with policies and
6-7 procedures established by the utilization review agent to assure
6-8 compliance with this section, and a description of such policies
6-9 and procedures shall be filed with the commissioner]. This
6-10 provision shall not be interpreted to require such qualifications
6-11 for personnel who perform clerical or administrative tasks.
6-12 (h) Utilization review conducted by a utilization review
6-13 agent shall be under the direction of a physician licensed to
6-14 practice medicine in the State of Texas [by a state licensing
6-15 agency in the United States].
6-16 (i) Each utilization review agent shall utilize written
6-17 medically acceptable screening criteria and review procedures which
6-18 are established and periodically evaluated and updated with
6-19 appropriate involvement from physicians, including practicing
6-20 physicians, dentists, and other health care providers. Utilization
6-21 review decisions shall be made in accordance with currently
6-22 accepted medical practices, taking into account special
6-23 circumstances of each case that may require deviation from the norm
6-24 stated in the screening criteria. Screening criteria must be
6-25 objective, clinically valid, compatible with established principles
6-26 of health care, and flexible enough to allow deviations from the
6-27 norms when justified on a case-by-case basis. Screening criteria
6-28 must be used to determine only whether to approve the requested
6-29 treatment. Denials must be referred to an appropriate physician,
6-30 dentist, or other health care provider to determine medical
7-1 necessity. Such written screening criteria and review procedures
7-2 shall be available for review and inspection to determine
7-3 appropriateness and compliance as deemed necessary by the
7-4 commissioner and copying as necessary for the commissioner to carry
7-5 out his or her lawful duties under this code, provided, however,
7-6 that any information obtained or acquired under the authority of
7-7 this subsection and article is confidential and privileged and not
7-8 subject to the open records law or subpoena except to the extent
7-9 necessary for the [board or] commissioner to enforce this article.
7-10 (k) Subject to the notice requirements of Section 5 of this
7-11 article, in any instance where the utilization review agent is
7-12 questioning the medical necessity or appropriateness of health care
7-13 services, the health care provider who ordered the services shall
7-14 be afforded a reasonable opportunity to discuss the plan of
7-15 treatment for the patient and the clinical basis for the
7-16 utilization review agent's decision with a physician [or, in the
7-17 case of a dental plan with a dentist,] prior to issuance of an
7-18 adverse determination.
7-19 (m) A utilization review agent shall establish and maintain
7-20 a complaint system that provides reasonable procedures for the
7-21 resolution of oral or written complaints initiated by enrollees,
7-22 patients, or health care providers concerning the utilization
7-23 review and shall maintain records of such [written] complaints for
7-24 three [two] years from the time the complaints are filed. The
7-25 complaint procedure shall include a written response to the
7-26 complainant by the agent within 30 [60] days. The utilization
7-27 review agent shall submit to the commissioner a summary report of
7-28 all complaints at such times and in such forms as the commissioner
7-29 [board] may require and shall permit the commissioner to examine
7-30 the complaints and all relevant documents at any time.
8-1 (n) The utilization review agent may delegate utilization
8-2 review to qualified personnel in the hospital or health care
8-3 facility where the health care services were or are to be provided.
8-4 However, such delegation shall not relieve the utilization review
8-5 agent of full responsibility for compliance with this article,
8-6 including the conduct of those to whom utilization review has been
8-7 delegated.
8-8 SECTION 4. Subsections (c) and (d), Section 5, Article
8-9 21.58A, Insurance Code, are amended to read as follows:
8-10 (c) In the event of an adverse determination, the
8-11 notification by the utilization review agent must include:
8-12 (1) the principal reasons for the adverse
8-13 determination;
8-14 (2) the clinical basis for the adverse determination;
8-15 (3) a description or the source of the screening
8-16 criteria that were utilized as guidelines in making the
8-17 determination; and
8-18 (4) [(3)] a description of the procedure for the
8-19 complaint and appeal process.
8-20 (d) The notification of adverse determination required by
8-21 this section shall be provided by the utilization review agent:
8-22 (1) within one working day by telephone or electronic
8-23 transmission to the provider of record in the case of a patient who
8-24 is hospitalized at the time of the adverse determination, to be
8-25 followed by a letter notifying the patient and the provider of
8-26 record of an adverse determination within three working days; [or]
8-27 (2) within three working days in writing to the
8-28 provider of record and the patient if the patient is not
8-29 hospitalized at the time of the adverse determination; or
8-30 (3) within the time appropriate to the circumstances
9-1 relating to the delivery of the services and the condition of the
9-2 patient, but in no case to exceed one hour from notification when
9-3 denying poststabilization care subsequent to emergency treatment as
9-4 requested by a treating physician or provider. In such
9-5 circumstances, notification shall be provided to the treating
9-6 physician or health care provider.
9-7 SECTION 5. Section 6, Article 21.58A, Insurance Code, is
9-8 amended to read as follows:
9-9 Sec. 6. APPEAL OF ADVERSE DETERMINATIONS OF UTILIZATION
9-10 REVIEW AGENTS. (a) A utilization review agent shall maintain and
9-11 make available a written description of [an] appeal procedures
9-12 involving [procedure of] an adverse determination.
9-13 (b) The procedures for appeals shall be reasonable and shall
9-14 include the following:
9-15 (1) a provision that an enrollee, a person acting on
9-16 behalf of the enrollee, or the enrollee's physician or health care
9-17 provider may appeal the adverse determination orally or in writing
9-18 [and shall be provided, on request, a clear and concise statement
9-19 of the clinical basis for the adverse determination];
9-20 (2) a provision that, within five working days from
9-21 receipt of the appeal, the utilization review agent shall send to
9-22 the appealing party a letter acknowledging the date of the
9-23 utilization review agent's receipt of the appeal and include a list
9-24 of documents needed to be submitted by the appealing party to the
9-25 utilization review agent for the appeal. Such letter must also
9-26 include provisions listed in this subsection. When the utilization
9-27 review agent receives an oral appeal of adverse determination, the
9-28 utilization review agent shall send a one-page appeal form to the
9-29 appealing party;
9-30 (3) a provision that appeal decisions shall be made by
10-1 a physician, provided that, if the appeal is denied and within 10
10-2 working days the health care provider sets forth in writing good
10-3 cause for having a particular type of a specialty provider review
10-4 the case, the denial shall be reviewed by a health care provider in
10-5 the same or similar specialty as typically manages the medical,
10-6 dental, or specialty condition, procedure, or treatment under
10-7 discussion for review of the adverse determination;
10-8 (4) in addition to the written appeal, a method for an
10-9 expedited appeal procedure for emergency care denials, denials of
10-10 care for life-threatening conditions, and denials of continued
10-11 stays for hospitalized patients. Such procedure[, which] shall
10-12 include a review by a health care provider who has not previously
10-13 reviewed the case who is of the same or a similar specialty as
10-14 typically manages the medical condition, procedure, or treatment
10-15 under review. The time frame in which[;] such appeal must be
10-16 completed shall be based on the medical or dental immediacy of the
10-17 condition, procedure, or treatment, but may in no event exceed one
10-18 working day from the date [no later than one working day following
10-19 the day on which the appeal], [including] all information necessary
10-20 to complete the appeal[,] is received [made to the utilization
10-21 review agent]; [and]
10-22 (5) a provision that after the utilization review
10-23 agent has sought review of the appeal of the adverse determination,
10-24 the utilization review agent shall issue a response letter to the
10-25 patient, a person acting on behalf of the patient, or the patient's
10-26 physician or health care provider explaining the resolution of the
10-27 appeal. Such letter shall include a statement of the specific
10-28 medical, dental, or contractual reasons for the resolution, the
10-29 clinical basis for such decision, and the specialization of any
10-30 physician or other provider consulted; and
11-1 (6) written notification to the appealing party of the
11-2 determination of the appeal, as soon as practical, but in no case
11-3 later than 30 days after the date the utilization review agent
11-4 receives the appeal [receiving all the required documentation of
11-5 the appeal. If the appeal is denied, the written notification shall
11-6 include the clinical basis for the appeal's denial and the
11-7 specialty of the physician making the denial].
11-8 SECTION 6. Section 7, Article 21.58A, Insurance Code, is
11-9 amended by adding Subsection (c) to read as follows:
11-10 (c) A utilization review agent must provide a written
11-11 description to the commissioner setting forth the procedures to be
11-12 used when responding to poststabilization care subsequent to
11-13 emergency treatment as requested by a treating physician or health
11-14 care provider.
11-15 SECTION 7. Section 8, Article 21.58A, Insurance Code, is
11-16 amended to read as follows:
11-17 Sec. 8. CONFIDENTIALITY. (a) A utilization review agent
11-18 shall preserve the confidentiality of individual medical records to
11-19 the extent required by law.
11-20 (b) A utilization review agent may not disclose or publish
11-21 individual medical records, personal information, or other
11-22 confidential information about a patient obtained in the
11-23 performance of utilization review without the prior written consent
11-24 of the patient or as otherwise required by law. If such
11-25 authorization is submitted by anyone other than the individual who
11-26 is the subject of the personal or confidential information
11-27 requested, such authorization must:
11-28 (1) be dated; and
11-29 (2) contain the signature of the individual who is the
11-30 subject of the personal or confidential information requested. The
12-1 signature must have been obtained one year or less prior to the
12-2 date the disclosure is sought or the authorization is invalid.
12-3 (c) A utilization review agent may provide confidential
12-4 information to a third party under contract or affiliated with the
12-5 utilization review agent for the sole purpose of performing or
12-6 assisting with utilization review. Information provided to third
12-7 parties shall remain confidential.
12-8 (d) If an individual submits a written request to the
12-9 utilization review agent for access to recorded personal
12-10 information about the individual, the utilization review agent
12-11 shall within 10 business days from the date such request is
12-12 received:
12-13 (1) inform the individual submitting the request of
12-14 the nature and substance of the recorded personal information in
12-15 writing; and
12-16 (2) permit the individual to see and copy, in person,
12-17 the recorded personal information pertaining to the individual or
12-18 to obtain a copy of the recorded personal information by mail, at
12-19 the discretion of the individual, unless the recorded personal
12-20 information is in coded form, in which case an accurate translation
12-21 in plain language shall be provided in writing.
12-22 (e) A utilization review agent's charges for providing a
12-23 copy of recorded personal information to individuals shall be
12-24 reasonable, as determined by rule of the commissioner, and may not
12-25 include any costs that are otherwise recouped as part of the charge
12-26 for utilization review.
12-27 (f) [(c)] The utilization review agent may not publish data
12-28 which identifies a particular physician or health care provider,
12-29 including any quality review studies or performance tracking data,
12-30 without prior written notice to the involved provider. This
13-1 prohibition does not apply to internal systems or reports used by
13-2 the utilization review agent.
13-3 (g) [(d)] Documents in the custody of the utilization review
13-4 agent that contain confidential patient information or physician or
13-5 health care provider financial data shall be destroyed by a method
13-6 which induces complete destruction of the information when the
13-7 agent determines the information is no longer needed.
13-8 (h) [(e)] All patient, physician, and health care provider
13-9 data shall be maintained by the utilization review agent in a
13-10 confidential manner which prevents unauthorized disclosure to third
13-11 parties. Nothing in this article shall be construed to allow a
13-12 utilization review agent to take actions that violate a state or
13-13 federal statute or regulation concerning confidentiality of patient
13-14 records.
13-15 (i) Notwithstanding the provisions in Subsections (a)
13-16 through (h) of this section, the utilization review agent shall
13-17 provide to the commissioner on request individual medical records
13-18 or other confidential information for determination of compliance
13-19 with this article. Such information shall be confidential and not
13-20 subject to the open records law.
13-21 SECTION 8. Subsections (a), (b), and (d), Section 9, Article
13-22 21.58A, Insurance Code, is amended to read as follows:
13-23 (a) If the commissioner believes that any person or entity
13-24 conducting utilization review pursuant to this article is in
13-25 violation of [a utilization review agent has violated or is
13-26 violating] this article or applicable regulations, the commissioner
13-27 shall notify the utilization review agent, health maintenance
13-28 organization, or insurer of the alleged violation and may compel
13-29 the production of any and all documents or other information as
13-30 necessary in order to determine whether or not such violation has
14-1 taken place [provided by this code].
14-2 (b) The commissioner may initiate the proceedings under this
14-3 section [after the 30th day after the date the commissioner
14-4 notifies the agent as required by Subsection (a) of this section].
14-5 (d) If [after notice and hearing] the commissioner
14-6 determines that the utilization review agent, health maintenance
14-7 organization, or insurer conducting utilization review pursuant to
14-8 this article has violated or is violating any provision of this
14-9 article, the commissioner may:
14-10 (1) impose sanctions under Section 7, Article 1.10 of
14-11 this code; [or]
14-12 (2) issue a cease and desist order under Article 1.10A
14-13 of this code; or
14-14 (3) assess administrative penalties under Article
14-15 1.10E of this code.
14-16 SECTION 9. Section 13, Article 21.58A, Insurance Code, is
14-17 amended to read as follows:
14-18 Sec. 13. AUTHORITY TO ADOPT RULES. The commissioner may
14-19 [board shall] have the authority to adopt rules and regulations to
14-20 implement the provisions of this article. The commissioner [board]
14-21 shall appoint an [11-member] advisory committee to advise the
14-22 commissioner [board] in developing rules and regulations to
14-23 administer this article as authorized by Section 2001.031,
14-24 Government Code. The committee's deliberations shall be subject to
14-25 the open meetings law. The committee shall include the public
14-26 counsel and one representative for each of the following:
14-27 insurance companies, health maintenance organizations, group
14-28 hospital service corporations, utilization review agents,
14-29 employers, physicians, dentists, hospitals, registered nurses, and
14-30 other health care providers.
15-1 SECTION 10. Section 14, Article 21.58A, Insurance Code, is
15-2 amended by amending Subsections (e), (g), and (h) and adding
15-3 Subsection (j) to read as follows:
15-4 (e) This article shall not apply to the terms or benefits of
15-5 employee welfare benefit plans as defined in Section 3(1) [31(I)]
15-6 of the Employee Retirement Income Security Act of 1974 (29 U.S.C.
15-7 Section 1002(1) [1002]).
15-8 (g) A health maintenance organization is not subject to this
15-9 article except as expressly provided in this subsection and
15-10 Subsection (i) of this section. If such health maintenance
15-11 organization performs utilization review as defined herein, it
15-12 shall, as a condition of licensure:
15-13 (1) comply with Sections 1, 2, 4, 5, 6, 7, 8, 9, 11,
15-14 12, 13, and 14 [4(b), (c), (e), (f), (h), (i), and (l)] of this
15-15 article, and the commissioner [board] shall promulgate rules for
15-16 appropriate verification and enforcement of compliance. However,
15-17 nothing in this article shall be construed to prohibit or limit the
15-18 distribution of a proportion of the savings from the reduction or
15-19 elimination of unnecessary medical services, treatment, supplies,
15-20 confinements, or days of confinement in a health care facility
15-21 through profit sharing, bonus, or withhold arrangements to
15-22 participating physicians or participating health care providers for
15-23 rendering health care services to enrollees; and
15-24 (2) [establish and maintain a system for:]
15-25 [(A) handling and responding to complaints by
15-26 enrollees, patients, or health care providers;]
15-27 [(B) providing health care providers with notice
15-28 of medical necessity or program requirements that have not been
15-29 met, including a reasonable opportunity to discuss the plan of
15-30 treatment and clinical basis for a utilization review determination
16-1 with a physician; and]
16-2 [(C) providing the enrollee, patient, and health
16-3 care provider an opportunity to appeal the determination; and]
16-4 [(3)] submit to assessment of maintenance taxes under
16-5 Article 20A.33, Texas Health Maintenance Organization Act (Article
16-6 20A.33, Vernon's Texas Insurance Code), to cover the costs of
16-7 administering compliance of health maintenance organizations under
16-8 this section.
16-9 (h) An insurer which delivers or issues for delivery a
16-10 health insurance policy in Texas and is subject to this code is not
16-11 subject to this article except as expressly provided in this
16-12 subsection and Subsection (i) of this section. If an insurer
16-13 performs utilization review as defined herein it shall, as a
16-14 condition of licensure, comply with Sections 1, 2, 4, 5, 6, 7, 8,
16-15 9, 11, 12, 13, and 14 [4 through 8] of this article, and the
16-16 commissioner [board] shall promulgate rules for appropriate
16-17 verification and enforcement of compliance. Such insurers shall be
16-18 subject to assessment of maintenance tax under Article 4.17 of this
16-19 code to cover the costs of administering compliance of insurers
16-20 under this section.
16-21 (j) A specialty utilization review agent is not subject to
16-22 Section 4(b), (c), (h), or (k) or Section 6(b)(3) of this article.
16-23 For purposes of this subsection, a specialty utilization review
16-24 agent means a utilization review agent that conducts utilization
16-25 review for specialty health care services, including but not
16-26 limited to dentistry, chiropractic, or physical therapy. A
16-27 specialty utilization review agent shall comply with the following
16-28 requirements:
16-29 (1) the utilization review plan, including
16-30 reconsideration and appeal requirements, shall be reviewed by a
17-1 health care provider of the appropriate specialty and conducted in
17-2 accordance with standards developed with input from a health care
17-3 provider of the appropriate specialty;
17-4 (2) personnel employed by or under contract with a
17-5 specialty utilization review agent to perform utilization review
17-6 shall be appropriately trained and qualified. Personnel who obtain
17-7 information directly from the physician or health care provider,
17-8 either orally or in writing, shall be nurses, physician assistants,
17-9 or other health care providers of the same specialty as the
17-10 utilization review agent and who are licensed or otherwise
17-11 authorized to provide the specialty health care service in this
17-12 state;
17-13 (3) utilization review conducted by a specialty
17-14 utilization review agent shall be conducted under the direction of
17-15 a health care provider of the same specialty and shall be licensed
17-16 or otherwise authorized to provide the specialty health care
17-17 service in this state;
17-18 (4) subject to the notice requirements of Section 5 of
17-19 this article, in any instance where the specialty utilization
17-20 review agent questions the medical necessity or appropriateness of
17-21 health care services, the health care provider who ordered the
17-22 services shall, prior to the issuance of an adverse determination,
17-23 be afforded a reasonable opportunity to discuss the plan of
17-24 treatment for the patient and the clinical basis for the decision
17-25 of the utilization review agent with a health care provider of the
17-26 same specialty as the utilization review agent; and
17-27 (5) appeal decisions shall be made by a physician or
17-28 health care provider in the same or a similar specialty as
17-29 typically manages the medical, dental, or specialty condition,
17-30 procedure, or treatment under discussion for review of the adverse
18-1 determination.
18-2 SECTION 11. This Act takes effect September 1, 1997.
18-3 SECTION 12. The importance of this legislation and the
18-4 crowded condition of the calendars in both houses create an
18-5 emergency and an imperative public necessity that the
18-6 constitutional rule requiring bills to be read on three several
18-7 days in each house be suspended, and this rule is hereby suspended.