By: Nelson, Harris, Sibley S.B. No. 384
Madla, Cain, Moncrief
A BILL TO BE ENTITLED
AN ACT
1-1 relating to utilization review under health benefit plans and
1-2 health insurance policies.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Section 2, Article 21.58A, Insurance Code, is
1-5 amended to read as follows:
1-6 Sec. 2. DEFINITIONS. In this article:
1-7 (1) "Administrative procedure act" means Chapter 2001,
1-8 Government Code [the Administrative Procedure and Texas Register
1-9 Act (Article 6252-13a, Vernon's Texas Civil Statutes)].
1-10 (2) "Administrator" means a person holding a
1-11 certificate of authority under Article 21.07-6 of this code.
1-12 (3) "Adverse determination" means a determination by a
1-13 utilization review agent that the health care services furnished or
1-14 proposed to be furnished to a patient are not medically necessary
1-15 or not appropriate in the allocation of health care resources.
1-16 (4) ["Board" means the State Board of Insurance.]
1-17 [(5)] "Certificate" means a certificate of
1-18 registration granted by the commissioner [board] to a utilization
1-19 review agent.
1-20 (5) [(6)] "Commissioner" means the commissioner of
1-21 insurance.
1-22 (6) [(7)] "Emergency care" means health care services
1-23 provided in a hospital emergency facility or comparable facility to
2-1 evaluate and stabilize medical conditions of a recent onset and
2-2 severity, including but not limited to severe pain, that would lead
2-3 a prudent layperson possessing an average knowledge of medicine and
2-4 health to believe that his or her condition, sickness, or injury is
2-5 of such a nature that failure to get immediate medical care could
2-6 result in:
2-7 (A) placing the patient's health in serious
2-8 jeopardy;
2-9 (B) serious impairment to bodily functions;
2-10 (C) serious dysfunction of any bodily organ or
2-11 part;
2-12 (D) serious disfigurement; or
2-13 (E) in the case of a pregnant woman, serious
2-14 jeopardy to the health of the fetus [bona fide emergency services
2-15 as defined in Section 2(I), Chapter 397, Acts of the 54th
2-16 Legislature, 1955 (Article 3.70-2, Vernon's Texas Insurance Code)
2-17 and Section 2(t), Texas Health Maintenance Organization Act
2-18 (Article 20A.02, Vernon's Texas Insurance Code)].
2-19 (7) [(8)] "Dental plan" means an insurance policy or
2-20 health benefit plan, including a policy written by a company
2-21 subject to Chapter 20 of this code, that provides coverage for
2-22 expenses for dental services.
2-23 (8) [(9)] "Enrollee" means a person covered by a
2-24 health insurance policy or plan and includes a person who is
2-25 covered as an eligible dependent of another person.
3-1 (9) [(10)] "Health benefit plan" means a plan of
3-2 benefits that defines the coverage provisions for health care for
3-3 enrollees offered or provided by any organization, public or
3-4 private, other than health insurance.
3-5 (10) [(11)] "Health care provider" means any person,
3-6 corporation, facility, or institution licensed by a state to
3-7 provide or otherwise lawfully providing health care services that
3-8 is eligible for independent reimbursement for those services.
3-9 (11) [(12)] "Health insurance policy" means an
3-10 insurance policy, including a policy written by a company subject
3-11 to Chapter 20 of this code, that provides coverage for medical or
3-12 surgical expenses incurred as a result of accident or sickness.
3-13 (12) "Life threatening" means diseases or conditions
3-14 where the likelihood of death is high unless the course of the
3-15 disease or condition is interrupted.
3-16 (13) "Nurse" means a professional or registered nurse,
3-17 a licensed vocational nurse, or a licensed practical nurse.
3-18 (14) "Open meetings law" means Chapter 551, Government
3-19 Code [271, Acts of the 60th Legislature, Regular Session, 1967
3-20 (Article 6252-17, Vernon's Texas Civil Statutes)].
3-21 (15) "Open records law" means Chapter 552, Government
3-22 Code [424, Acts of the 63rd Legislature, Regular Session, 1973
3-23 (Article 6252-17a, Vernon's Texas Civil Statutes)].
3-24 (16) "Patient" means the enrollee or an eligible
3-25 dependent of the enrollee under a health benefit plan or health
4-1 insurance plan.
4-2 (17) "Payor" means:
4-3 (A) an insurer writing health insurance
4-4 policies;
4-5 (B) any preferred provider organization, health
4-6 maintenance organization, self-insurance plan; or
4-7 (C) any other person or entity which provides,
4-8 offers to provide, or administers hospital, outpatient, medical, or
4-9 other health benefits to persons treated by a health care provider
4-10 in this state pursuant to any policy, plan, or contract.
4-11 (18) "Physician" means a licensed doctor of medicine
4-12 or a doctor of osteopathy.
4-13 (19) "Provider of record" means the physician or other
4-14 health care provider that has primary responsibility for the care,
4-15 treatment, and services rendered to the enrollee and includes any
4-16 health care facility when treatment is rendered on an inpatient or
4-17 outpatient basis.
4-18 (20) "Utilization review" means a system for
4-19 prospective or concurrent review of the medical necessity and
4-20 appropriateness of health care services being provided or proposed
4-21 to be provided to an individual within this state. Utilization
4-22 review shall not include elective requests for clarification of
4-23 coverage.
4-24 (21) "Utilization review agent" means an entity that
4-25 conducts utilization review for:
5-1 (A) an employer with employees in this state who
5-2 are covered under a health benefit plan or health insurance policy;
5-3 (B) a payor; or
5-4 (C) an administrator.
5-5 (22) "Utilization review plan" means the screening
5-6 criteria and utilization review procedures of a utilization review
5-7 agent.
5-8 (23) "Working day" means a weekday, excluding a legal
5-9 holiday.
5-10 SECTION 2. Subsections (b), (d), (e), and (f), Section 3,
5-11 Article 21.58A, Insurance Code, are amended to read as follows:
5-12 (b) The commissioner may only issue a certificate to an
5-13 applicant that has met all the requirements of this article and all
5-14 applicable rules and regulations of the commissioner [board].
5-15 (d) Certification may be renewed biennially by filing, not
5-16 later than March 1, a renewal form with the commissioner
5-17 accompanied by a renewal fee in an amount set by the commissioner
5-18 [board].
5-19 (e) The commissioner shall promulgate certification and
5-20 renewal forms to be filed under this section. The form for initial
5-21 certification must require the following:
5-22 (1) the entity's name, address, telephone number, and
5-23 normal business hours;
5-24 (2) the name and address of an agent for service of
5-25 process in this state;
6-1 (3) a summary of the utilization review plan, but in
6-2 no event shall proprietary details be subject to inclusion in the
6-3 summary;
6-4 (4) information concerning the personnel categories
6-5 that will perform utilization review for the utilization review
6-6 agent;
6-7 (5) a copy of the procedure established by the
6-8 utilization review agent as required by this article for appeal of
6-9 an adverse determination;
6-10 (6) a certification that the utilization review agent
6-11 will comply with the provisions of this article; and
6-12 (7) a copy of the procedures for handling oral and
6-13 written complaints by enrollees, patients, or health care
6-14 providers.
6-15 (f) The commissioner [board] shall establish, administer,
6-16 and enforce the certification and renewal fees under this section
6-17 in amounts not greater than that necessary to cover the cost of
6-18 administration of this article.
6-19 SECTION 3. Subsections (c), (h), (i), (k), (m), and (n),
6-20 Section 4, Article 21.58A, Insurance Code, are amended to read as
6-21 follows:
6-22 (c) Personnel employed by or under contract with the
6-23 utilization review agent to perform utilization review shall be
6-24 appropriately trained and qualified. Personnel who obtain
6-25 information regarding a patient's specific medical condition,
7-1 diagnosis, and treatment options or protocols directly from the
7-2 physician or health care provider, either orally or in writing, and
7-3 who are not physicians shall be nurses or[,] physician assistants.
7-4 Personnel who obtain other information directly from the physician
7-5 or health care provider, either orally or in writing, and who are
7-6 not physicians shall be nurses, physician assistants, registered
7-7 records administrators, or accredited records technicians, who are
7-8 either licensed or certified, or shall be individuals who have
7-9 received formal orientation and training in accordance with
7-10 policies and procedures established by the utilization review agent
7-11 to assure compliance with this section, and a description of such
7-12 policies and procedures shall be filed with the commissioner. This
7-13 provision shall not be interpreted to require such qualifications
7-14 for personnel who perform clerical or administrative tasks.
7-15 (h) Utilization review conducted by a utilization review
7-16 agent shall be under the direction of a physician licensed to
7-17 practice medicine by a state licensing agency in the United States.
7-18 (i) Each utilization review agent shall utilize written
7-19 medically acceptable screening criteria and review procedures which
7-20 are established and periodically evaluated and updated with
7-21 appropriate involvement from physicians, including practicing
7-22 physicians, dentists, and other health care providers. Utilization
7-23 review decisions shall be made in accordance with currently
7-24 accepted medical or health care practices, taking into account
7-25 special circumstances of each case that may require deviation from
8-1 the norm stated in the screening criteria. Screening criteria must
8-2 be objective, clinically valid, compatible with established
8-3 principles of health care, and flexible enough to allow deviations
8-4 from the norms when justified on a case-by-case basis. Screening
8-5 criteria must be used to determine only whether to approve the
8-6 requested treatment. Denials must be referred to an appropriate
8-7 physician, dentist, or other health care provider to determine
8-8 medical necessity. Such written screening criteria and review
8-9 procedures shall be available for review and inspection to
8-10 determine appropriateness and compliance as deemed necessary by the
8-11 commissioner and copying as necessary for the commissioner to carry
8-12 out his or her lawful duties under this code, provided, however,
8-13 that any information obtained or acquired under the authority of
8-14 this subsection and article is confidential and privileged and not
8-15 subject to the open records law or subpoena except to the extent
8-16 necessary for the [board or] commissioner to enforce this article.
8-17 (k) Subject to the notice requirements of Section 5 of this
8-18 article, in any instance where the utilization review agent is
8-19 questioning the medical necessity or appropriateness of health care
8-20 services, the health care provider who ordered the services shall
8-21 be afforded a reasonable opportunity to discuss the plan of
8-22 treatment for the patient and the clinical basis for the
8-23 utilization review agent's decision with a physician [or, in the
8-24 case of a dental plan with a dentist,] prior to issuance of an
8-25 adverse determination.
9-1 (m) A utilization review agent shall establish and maintain
9-2 a complaint system that provides reasonable procedures for the
9-3 resolution of oral or written complaints initiated by enrollees,
9-4 patients, or health care providers concerning the utilization
9-5 review and shall maintain records of such [written] complaints for
9-6 three [two] years from the time the complaints are filed. The
9-7 complaint procedure shall include a written response to the
9-8 complainant by the agent within 30 [60] days. The utilization
9-9 review agent shall submit to the commissioner a summary report of
9-10 all complaints at such times and in such forms as the commissioner
9-11 [board] may require and shall permit the commissioner to examine
9-12 the complaints and all relevant documents at any time.
9-13 (n) The utilization review agent may delegate utilization
9-14 review to qualified personnel in the hospital or health care
9-15 facility where the health care services were or are to be provided.
9-16 However, such delegation shall not relieve the utilization review
9-17 agent of full responsibility for compliance with this article,
9-18 including the conduct of those to whom utilization review has been
9-19 delegated.
9-20 SECTION 4. Subsections (c) and (d), Section 5, Article
9-21 21.58A, Insurance Code, are amended to read as follows:
9-22 (c) In the event of an adverse determination, the
9-23 notification by the utilization review agent must include:
9-24 (1) the principal reasons for the adverse
9-25 determination;
10-1 (2) the clinical basis for the adverse determination;
10-2 (3) a description or the source of the screening
10-3 criteria that were utilized as guidelines in making the
10-4 determination; and
10-5 (4) [(3)] a description of the procedure for the
10-6 complaint and appeal process.
10-7 (d) The notification of adverse determination required by
10-8 this section shall be provided by the utilization review agent:
10-9 (1) within one working day by telephone or electronic
10-10 transmission to the provider of record in the case of a patient who
10-11 is hospitalized at the time of the adverse determination, to be
10-12 followed by a letter notifying the patient and the provider of
10-13 record of an adverse determination within three working days; [or]
10-14 (2) within three working days in writing to the
10-15 provider of record and the patient if the patient is not
10-16 hospitalized at the time of the adverse determination; or
10-17 (3) within the time appropriate to the circumstances
10-18 relating to the delivery of the services and the condition of the
10-19 patient, but in no case to exceed one hour from notification when
10-20 denying poststabilization care subsequent to emergency treatment as
10-21 requested by a treating physician or provider. In such
10-22 circumstances, notification shall be provided to the treating
10-23 physician or health care provider.
10-24 SECTION 5. Section 6, Article 21.58A, Insurance Code, is
10-25 amended to read as follows:
11-1 Sec. 6. APPEAL OF ADVERSE DETERMINATIONS OF UTILIZATION
11-2 REVIEW AGENTS. (a) A utilization review agent shall maintain and
11-3 make available a written description of [an] appeal procedures
11-4 involving [procedure of] an adverse determination.
11-5 (b) The procedures for appeals shall be reasonable and shall
11-6 include the following:
11-7 (1) a provision that an enrollee, a person acting on
11-8 behalf of the enrollee, or the enrollee's physician or health care
11-9 provider may appeal the adverse determination orally or in writing
11-10 [and shall be provided, on request, a clear and concise statement
11-11 of the clinical basis for the adverse determination];
11-12 (2) a provision that, within five working days from
11-13 receipt of the appeal, the utilization review agent shall send to
11-14 the appealing party a letter acknowledging the date of the
11-15 utilization review agent's receipt of the appeal and include a list
11-16 of documents needed to be submitted by the appealing party to the
11-17 utilization review agent for the appeal. Such letter must also
11-18 include provisions listed in this subsection. When the utilization
11-19 review agent receives an oral appeal of adverse determination, the
11-20 utilization review agent shall send a one-page appeal form to the
11-21 appealing party;
11-22 (3) a provision that appeal decisions shall be made by
11-23 a physician, provided that, if the appeal is denied and within 10
11-24 working days the health care provider sets forth in writing good
11-25 cause for having a particular type of a specialty provider review
12-1 the case, the denial shall be reviewed by a health care provider in
12-2 the same or similar specialty as typically manages the medical,
12-3 dental, or specialty condition, procedure, or treatment under
12-4 discussion for review of the adverse determination, and such
12-5 specialty review shall be completed within 15 working days of
12-6 receipt of the request;
12-7 (4) in addition to the written appeal, a method for an
12-8 expedited appeal procedure for emergency care denials, denials of
12-9 care for life-threatening conditions, and denials of continued
12-10 stays for hospitalized patients. Such procedure[, which] shall
12-11 include a review by a health care provider who has not previously
12-12 reviewed the case who is of the same or a similar specialty as
12-13 typically manages the medical condition, procedure, or treatment
12-14 under review. The time frame in which[;] such appeal must be
12-15 completed shall be based on the medical or dental immediacy of the
12-16 condition, procedure, or treatment, but may in no event exceed one
12-17 working day from the date [no later than one working day following
12-18 the day on which the appeal], [including] all information necessary
12-19 to complete the appeal[,] is received [made to the utilization
12-20 review agent]; [and]
12-21 (5) a provision that after the utilization review
12-22 agent has sought review of the appeal of the adverse determination,
12-23 the utilization review agent shall issue a response letter to the
12-24 patient, a person acting on behalf of the patient, or the patient's
12-25 physician or health care provider explaining the resolution of the
13-1 appeal. Such letter shall include a statement of the specific
13-2 medical, dental, or contractual reasons for the resolution, the
13-3 clinical basis for such decision, and the specialization of any
13-4 physician or other provider consulted; and
13-5 (6) written notification to the appealing party of the
13-6 determination of the appeal, as soon as practical, but in no case
13-7 later than 30 days after the date the utilization review agent
13-8 receives the appeal [receiving all the required documentation of
13-9 the appeal. If the appeal is denied, the written notification
13-10 shall include the clinical basis for the appeal's denial and the
13-11 specialty of the physician making the denial].
13-12 SECTION 6. Section 7, Article 21.58A, Insurance Code, is
13-13 amended by adding Subsection (c) to read as follows:
13-14 (c) A utilization review agent must provide a written
13-15 description to the commissioner setting forth the procedures to be
13-16 used when responding to poststabilization care subsequent to
13-17 emergency treatment as requested by a treating physician or health
13-18 care provider.
13-19 SECTION 7. Section 8, Article 21.58A, Insurance Code, is
13-20 amended to read as follows:
13-21 Sec. 8. CONFIDENTIALITY. (a) A utilization review agent
13-22 shall preserve the confidentiality of individual medical records to
13-23 the extent required by law.
13-24 (b) A utilization review agent may not disclose or publish
13-25 individual medical records, personal information, or other
14-1 confidential information about a patient obtained in the
14-2 performance of utilization review without the prior written consent
14-3 of the patient or as otherwise required by law. If such
14-4 authorization is submitted by anyone other than the individual who
14-5 is the subject of the personal or confidential information
14-6 requested, such authorization must:
14-7 (1) be dated; and
14-8 (2) contain the signature of the individual who is the
14-9 subject of the personal or confidential information requested. The
14-10 signature must have been obtained one year or less prior to the
14-11 date the disclosure is sought or the authorization is invalid.
14-12 (c) A utilization review agent may provide confidential
14-13 information to a third party under contract or affiliated with the
14-14 utilization review agent for the sole purpose of performing or
14-15 assisting with utilization review. Information provided to third
14-16 parties shall remain confidential.
14-17 (d) If an individual submits a written request to the
14-18 utilization review agent for access to recorded personal
14-19 information about the individual, the utilization review agent
14-20 shall within 10 business days from the date such request is
14-21 received:
14-22 (1) inform the individual submitting the request of
14-23 the nature and substance of the recorded personal information in
14-24 writing; and
14-25 (2) permit the individual to see and copy, in person,
15-1 the recorded personal information pertaining to the individual or
15-2 to obtain a copy of the recorded personal information by mail, at
15-3 the discretion of the individual, unless the recorded personal
15-4 information is in coded form, in which case an accurate translation
15-5 in plain language shall be provided in writing.
15-6 (e) A utilization review agent's charges for providing a
15-7 copy of recorded personal information to individuals shall be
15-8 reasonable, as determined by rule of the commissioner, and may not
15-9 include any costs that are otherwise recouped as part of the charge
15-10 for utilization review.
15-11 (f) [(c)] The utilization review agent may not publish data
15-12 which identifies a particular physician or health care provider,
15-13 including any quality review studies or performance tracking data,
15-14 without prior written notice to the involved provider. This
15-15 prohibition does not apply to internal systems or reports used by
15-16 the utilization review agent.
15-17 (g) [(d)] Documents in the custody of the utilization review
15-18 agent that contain confidential patient information or physician or
15-19 health care provider financial data shall be destroyed by a method
15-20 which induces complete destruction of the information when the
15-21 agent determines the information is no longer needed.
15-22 (h) [(e)] All patient, physician, and health care provider
15-23 data shall be maintained by the utilization review agent in a
15-24 confidential manner which prevents unauthorized disclosure to third
15-25 parties. Nothing in this article shall be construed to allow a
16-1 utilization review agent to take actions that violate a state or
16-2 federal statute or regulation concerning confidentiality of patient
16-3 records.
16-4 (i) Notwithstanding the provisions in Subsections (a)
16-5 through (h) of this section, the utilization review agent shall
16-6 provide to the commissioner on request individual medical records
16-7 or other confidential information for determination of compliance
16-8 with this article. Such information shall be confidential and not
16-9 subject to the open records law.
16-10 SECTION 8. Subsections (a), (b), and (d), Section 9, Article
16-11 21.58A, Insurance Code, is amended to read as follows:
16-12 (a) If the commissioner believes that any person or entity
16-13 conducting utilization review pursuant to this article is in
16-14 violation of [a utilization review agent has violated or is
16-15 violating] this article or applicable regulations, the commissioner
16-16 shall notify the utilization review agent, health maintenance
16-17 organization, or insurer of the alleged violation and may compel
16-18 the production of any and all documents or other information as
16-19 necessary in order to determine whether or not such violation has
16-20 taken place [provided by this code].
16-21 (b) The commissioner may initiate the proceedings under this
16-22 section [after the 30th day after the date the commissioner
16-23 notifies the agent as required by Subsection (a) of this section].
16-24 (d) If [after notice and hearing] the commissioner
16-25 determines that the utilization review agent, health maintenance
17-1 organization, or insurer conducting utilization review pursuant to
17-2 this article has violated or is violating any provision of this
17-3 article, the commissioner may:
17-4 (1) impose sanctions under Section 7, Article 1.10 of
17-5 this code; [or]
17-6 (2) issue a cease and desist order under Article 1.10A
17-7 of this code; or
17-8 (3) assess administrative penalties under Article
17-9 1.10E of this code.
17-10 SECTION 9. Section 13, Article 21.58A, Insurance Code, is
17-11 amended to read as follows:
17-12 Sec. 13. AUTHORITY TO ADOPT RULES. The commissioner may
17-13 [board shall] have the authority to adopt rules and regulations to
17-14 implement the provisions of this article. The commissioner [board]
17-15 shall appoint an [11-member] advisory committee to advise the
17-16 commissioner [board] in developing rules and regulations to
17-17 administer this article as authorized by Section 2001.031,
17-18 Government Code. The committee's deliberations shall be subject to
17-19 the open meetings law. The committee shall include the public
17-20 counsel and one representative for each of the following:
17-21 insurance companies, health maintenance organizations, group
17-22 hospital service corporations, utilization review agents,
17-23 employers, physicians, dentists, hospitals, registered nurses, and
17-24 other health care providers.
17-25 SECTION 10. Section 14, Article 21.58A, Insurance Code, is
18-1 amended by amending Subsections (e), (g), and (h) and adding
18-2 Subsection (j) to read as follows:
18-3 (e) This article shall not apply to the terms or benefits of
18-4 employee welfare benefit plans as defined in Section 3(1) [31(I)]
18-5 of the Employee Retirement Income Security Act of 1974 (29 U.S.C.
18-6 Section 1002(1) [1002]).
18-7 (g) A health maintenance organization is not subject to this
18-8 article except as expressly provided in this subsection and
18-9 Subsection (i) of this section. If such health maintenance
18-10 organization performs utilization review as defined herein, it
18-11 shall, as a condition of licensure:
18-12 (1) comply with Sections 1, 2, 4, 5, 6, 7, 8, 9, 11,
18-13 12, 13, and 14 [4(b), (c), (e), (f), (h), (i), and (l)] of this
18-14 article, and the commissioner [board] shall promulgate rules for
18-15 appropriate verification and enforcement of compliance. However,
18-16 nothing in this article shall be construed to prohibit or limit the
18-17 distribution of a proportion of the savings from the reduction or
18-18 elimination of unnecessary medical services, treatment, supplies,
18-19 confinements, or days of confinement in a health care facility
18-20 through profit sharing, bonus, or withhold arrangements to
18-21 participating physicians or participating health care providers for
18-22 rendering health care services to enrollees; and
18-23 (2) [establish and maintain a system for:]
18-24 [(A) handling and responding to complaints by
18-25 enrollees, patients, or health care providers;]
19-1 [(B) providing health care providers with notice
19-2 of medical necessity or program requirements that have not been
19-3 met, including a reasonable opportunity to discuss the plan of
19-4 treatment and clinical basis for a utilization review determination
19-5 with a physician; and]
19-6 [(C) providing the enrollee, patient, and health
19-7 care provider an opportunity to appeal the determination; and]
19-8 [(3)] submit to assessment of maintenance taxes under
19-9 Article 20A.33, Texas Health Maintenance Organization Act (Article
19-10 20A.33, Vernon's Texas Insurance Code), to cover the costs of
19-11 administering compliance of health maintenance organizations under
19-12 this section.
19-13 (h) An insurer which delivers or issues for delivery a
19-14 health insurance policy in Texas and is subject to this code is not
19-15 subject to this article except as expressly provided in this
19-16 subsection and Subsection (i) of this section. If an insurer
19-17 performs utilization review as defined herein it shall, as a
19-18 condition of licensure, comply with Sections 1, 2, 4, 5, 6, 7, 8,
19-19 9, 11, 12, 13, and 14 [4 through 8] of this article, and the
19-20 commissioner [board] shall promulgate rules for appropriate
19-21 verification and enforcement of compliance. Such insurers shall be
19-22 subject to assessment of maintenance tax under Article 4.17 of this
19-23 code to cover the costs of administering compliance of insurers
19-24 under this section.
19-25 (j) A specialty utilization review agent is not subject to
20-1 Section 4(b), (c), (h), or (k) or Section 6(b)(3) of this article.
20-2 For purposes of this subsection, a specialty utilization review
20-3 agent means a utilization review agent that conducts utilization
20-4 review for specialty health care services, including but not
20-5 limited to dentistry, chiropractic, or physical therapy. A
20-6 specialty utilization review agent shall comply with the following
20-7 requirements:
20-8 (1) the utilization review plan, including
20-9 reconsideration and appeal requirements, shall be reviewed by a
20-10 health care provider of the appropriate specialty and conducted in
20-11 accordance with standards developed with input from a health care
20-12 provider of the appropriate specialty;
20-13 (2) personnel employed by or under contract with a
20-14 specialty utilization review agent to perform utilization review
20-15 shall be appropriately trained and qualified. Personnel who obtain
20-16 information directly from the physician or health care provider,
20-17 either orally or in writing, shall be nurses, physician assistants,
20-18 or other health care providers of the same specialty as the
20-19 utilization review agent and who are licensed or otherwise
20-20 authorized to provide the specialty health care service by a state
20-21 licensing agency in the United States;
20-22 (3) utilization review conducted by a specialty
20-23 utilization review agent shall be conducted under the direction of
20-24 a health care provider of the same specialty and shall be licensed
20-25 or otherwise authorized to provide the specialty health care
21-1 service by a state licensing agency in the United States;
21-2 (4) subject to the notice requirements of Section 5 of
21-3 this article, in any instance where the specialty utilization
21-4 review agent questions the medical necessity or appropriateness of
21-5 health care services, the health care provider who ordered the
21-6 services shall, prior to the issuance of an adverse determination,
21-7 be afforded a reasonable opportunity to discuss the plan of
21-8 treatment for the patient and the clinical basis for the decision
21-9 of the utilization review agent with a health care provider of the
21-10 same specialty as the utilization review agent; and
21-11 (5) appeal decisions shall be made by a physician or
21-12 health care provider in the same or a similar specialty as
21-13 typically manages the medical, dental, or specialty condition,
21-14 procedure, or treatment under discussion for review of the adverse
21-15 determination.
21-16 SECTION 11. This Act takes effect September 1, 1997.
21-17 SECTION 12. The importance of this legislation and the
21-18 crowded condition of the calendars in both houses create an
21-19 emergency and an imperative public necessity that the
21-20 constitutional rule requiring bills to be read on three several
21-21 days in each house be suspended, and this rule is hereby suspended.