By: Nelson, Harris S.B. No. 384
Sibley, Madla, Cain
97S0235/1
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 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
3-1 benefits that defines the coverage provisions for health care for
3-2 enrollees offered or provided by any organization, public or
3-3 private, other than health insurance.
3-4 (10) [(11)] "Health care provider" means any person,
3-5 corporation, facility, or institution licensed by a state to
3-6 provide or otherwise lawfully providing health care services that
3-7 is eligible for independent reimbursement for those services.
3-8 (11) [(12)] "Health insurance policy" means an
3-9 insurance policy, including a policy written by a company subject
3-10 to Chapter 20 of this code, that provides coverage for medical or
3-11 surgical expenses incurred as a result of accident or sickness.
3-12 (12) [(13)] "Nurse" means a professional or registered
3-13 nurse, a licensed vocational nurse, or a licensed practical nurse.
3-14 (13) [(14)] "Open meetings law" means Chapter 551,
3-15 Government Code [271, Acts of the 60th Legislature, Regular
3-16 Session, 1967 (Article 6252-17, Vernon's Texas Civil Statutes)].
3-17 (14) [(15)] "Open records law" means Chapter 552,
3-18 Government Code [424, Acts of the 63rd Legislature, Regular
3-19 Session, 1973 (Article 6252-17a, Vernon's Texas Civil Statutes)].
3-20 (15) [(16)] "Patient" means the enrollee or an
3-21 eligible dependent of the enrollee under a health benefit plan or
3-22 health insurance plan.
3-23 (16) [(17)] "Payor" means:
3-24 (A) an insurer writing health insurance
3-25 policies;
4-1 (B) any preferred provider organization, health
4-2 maintenance organization, self-insurance plan; or
4-3 (C) any other person or entity which provides,
4-4 offers to provide, or administers hospital, outpatient, medical, or
4-5 other health benefits to persons treated by a health care provider
4-6 in this state pursuant to any policy, plan, or contract.
4-7 (17) [(18)] "Physician" means a licensed doctor of
4-8 medicine or a doctor of osteopathy.
4-9 (18) [(19)] "Provider of record" means the physician
4-10 or other health care provider that has primary responsibility for
4-11 the care, treatment, and services rendered to the enrollee and
4-12 includes any health care facility when treatment is rendered on an
4-13 inpatient or outpatient basis.
4-14 (19) [(20)] "Utilization review" means a system for
4-15 prospective or concurrent review of the medical necessity and
4-16 appropriateness of health care services being provided or proposed
4-17 to be provided to an individual within this state. Utilization
4-18 review shall not include elective requests for clarification of
4-19 coverage.
4-20 (20) [(21)] "Utilization review agent" means an entity
4-21 that conducts utilization review for:
4-22 (A) an employer with employees in this state who
4-23 are covered under a health benefit plan or health insurance policy;
4-24 (B) a payor; or
4-25 (C) an administrator.
5-1 (21) [(22)] "Utilization review plan" means the
5-2 screening criteria and utilization review procedures of a
5-3 utilization review agent.
5-4 (22) [(23)] "Working day" means a weekday, excluding a
5-5 legal holiday.
5-6 SECTION 2. Subsections (b), (d), (e), and (f), Section 3,
5-7 Article 21.58A, Insurance Code, are amended to read as follows:
5-8 (b) The commissioner may only issue a certificate to an
5-9 applicant that has met all the requirements of this article and all
5-10 applicable rules and regulations of the commissioner [board].
5-11 (d) Certification may be renewed biennially by filing, not
5-12 later than March 1, a renewal form with the commissioner
5-13 accompanied by a renewal fee in an amount set by the commissioner
5-14 [board].
5-15 (e) The commissioner shall promulgate certification and
5-16 renewal forms to be filed under this section. The form for initial
5-17 certification must require the following:
5-18 (1) the entity's name, address, telephone number, and
5-19 normal business hours;
5-20 (2) the name and address of an agent for service of
5-21 process in this state;
5-22 (3) a summary of the utilization review plan, but in
5-23 no event shall proprietary details be subject to inclusion in the
5-24 summary;
5-25 (4) information concerning the personnel categories
6-1 that will perform utilization review for the utilization review
6-2 agent;
6-3 (5) a copy of the procedure established by the
6-4 utilization review agent as required by this article for appeal of
6-5 an adverse determination;
6-6 (6) a certification that the utilization review agent
6-7 will comply with the provisions of this article; and
6-8 (7) a copy of the procedures for handling oral and
6-9 written complaints by enrollees, patients, or health care
6-10 providers.
6-11 (f) The commissioner [board] shall establish, administer,
6-12 and enforce the certification and renewal fees under this section
6-13 in amounts not greater than that necessary to cover the cost of
6-14 administration of this article.
6-15 SECTION 3. Subsections (c), (h), (i), (k), (m), and (n),
6-16 Section 4, Article 21.58A, Insurance Code, are amended to read as
6-17 follows:
6-18 (c) Personnel employed by or under contract with the
6-19 utilization review agent to perform utilization review shall be
6-20 appropriately trained and qualified. Personnel who obtain
6-21 information directly from the physician or health care provider,
6-22 either orally or in writing, and who are not physicians shall be
6-23 nurses or[,] physician assistants, [registered records
6-24 administrators, or accredited records technicians,] who are either
6-25 licensed or certified[, or shall be individuals who have received
7-1 formal orientation and training in accordance with policies and
7-2 procedures established by the utilization review agent to assure
7-3 compliance with this section, and a description of such policies
7-4 and procedures shall be filed with the commissioner]. This
7-5 provision shall not be interpreted to require such qualifications
7-6 for personnel who perform clerical or administrative tasks.
7-7 (h) Utilization review conducted by a utilization review
7-8 agent shall be under the direction of a physician licensed to
7-9 practice medicine in the State of Texas [by a state licensing
7-10 agency in the United States].
7-11 (i) Each utilization review agent shall utilize written
7-12 medically acceptable screening criteria and review procedures which
7-13 are established and periodically evaluated and updated with
7-14 appropriate involvement from physicians, including practicing
7-15 physicians, dentists, and other health care providers. Utilization
7-16 review decisions shall be made in accordance with currently
7-17 accepted medical practices, taking into account special
7-18 circumstances of each case that may require deviation from the norm
7-19 stated in the screening criteria. Screening criteria must be
7-20 objective, clinically valid, compatible with established principles
7-21 of health care, and flexible enough to allow deviations from the
7-22 norms when justified on a case-by-case basis. Screening criteria
7-23 must be used to determine only whether to approve the requested
7-24 treatment. Denials must be referred to an appropriate physician,
7-25 dentist, or other health care provider to determine medical
8-1 necessity. Such written screening criteria and review procedures
8-2 shall be available for review and inspection to determine
8-3 appropriateness and compliance as deemed necessary by the
8-4 commissioner and copying as necessary for the commissioner to carry
8-5 out his or her lawful duties under this code, provided, however,
8-6 that any information obtained or acquired under the authority of
8-7 this subsection and article is confidential and privileged and not
8-8 subject to the open records law or subpoena except to the extent
8-9 necessary for the [board or] commissioner to enforce this article.
8-10 (k) Subject to the notice requirements of Section 5 of this
8-11 article, in any instance where the utilization review agent is
8-12 questioning the medical necessity or appropriateness of health care
8-13 services, the health care provider who ordered the services shall
8-14 be afforded a reasonable opportunity to discuss the plan of
8-15 treatment for the patient and the clinical basis for the
8-16 utilization review agent's decision with a physician [or, in the
8-17 case of a dental plan with a dentist,] prior to issuance of an
8-18 adverse determination.
8-19 (m) A utilization review agent shall establish and maintain
8-20 a complaint system that provides reasonable procedures for the
8-21 resolution of oral or written complaints initiated by enrollees,
8-22 patients, or health care providers concerning the utilization
8-23 review and shall maintain records of such [written] complaints for
8-24 three [two] years from the time the complaints are filed. The
8-25 complaint procedure shall include a written response to the
9-1 complainant by the agent within 30 [60] days. The utilization
9-2 review agent shall submit to the commissioner a summary report of
9-3 all complaints at such times and in such forms as the commissioner
9-4 [board] may require and shall permit the commissioner to examine
9-5 the complaints and all relevant documents at any time.
9-6 (n) The utilization review agent may delegate utilization
9-7 review to qualified personnel in the hospital or health care
9-8 facility where the health care services were or are to be provided.
9-9 However, such delegation shall not relieve the utilization review
9-10 agent of full responsibility for compliance with this article,
9-11 including the conduct of those to whom utilization review has been
9-12 delegated.
9-13 SECTION 4. Subsections (c) and (d), Section 5, Article
9-14 21.58A, Insurance Code, are amended to read as follows:
9-15 (c) In the event of an adverse determination, the
9-16 notification by the utilization review agent must include:
9-17 (1) the principal reasons for the adverse
9-18 determination;
9-19 (2) the clinical basis for the adverse determination;
9-20 (3) a description or the source of the screening
9-21 criteria that were utilized as guidelines in making the
9-22 determination; and
9-23 (4) [(3)] a description of the procedure for the
9-24 complaint and appeal process.
9-25 (d) The notification of adverse determination required by
10-1 this section shall be provided by the utilization review agent:
10-2 (1) within one working day by telephone or electronic
10-3 transmission to the provider of record in the case of a patient who
10-4 is hospitalized at the time of the adverse determination, to be
10-5 followed by a letter notifying the patient and the provider of
10-6 record of an adverse determination within three working days; [or]
10-7 (2) within three working days in writing to the
10-8 provider of record and the patient if the patient is not
10-9 hospitalized at the time of the adverse determination; or
10-10 (3) within the time appropriate to the circumstances
10-11 relating to the delivery of the services and the condition of the
10-12 patient, but in no case to exceed one hour from notification when
10-13 denying poststabilization care subsequent to emergency treatment as
10-14 requested by a treating physician or provider. In such
10-15 circumstances, notification shall be provided to the treating
10-16 physician or health care provider.
10-17 SECTION 5. Section 6, Article 21.58A, Insurance Code, is
10-18 amended to read as follows:
10-19 Sec. 6. APPEAL OF ADVERSE DETERMINATIONS OF UTILIZATION
10-20 REVIEW AGENTS. (a) A utilization review agent shall maintain and
10-21 make available a written description of [an] appeal procedures
10-22 involving [procedure of] an adverse determination.
10-23 (b) The procedures for appeals shall be reasonable and shall
10-24 include the following:
10-25 (1) a provision that an enrollee, a person acting on
11-1 behalf of the enrollee, or the enrollee's physician or health care
11-2 provider may appeal the adverse determination orally or in writing
11-3 [and shall be provided, on request, a clear and concise statement
11-4 of the clinical basis for the adverse determination];
11-5 (2) a provision that, within five working days from
11-6 receipt of the appeal, the utilization review agent shall send to
11-7 the appealing party a letter acknowledging the date of the
11-8 utilization review agent's receipt of the appeal and include a list
11-9 of documents needed to be submitted by the appealing party to the
11-10 utilization review agent for the appeal. Such letter must also
11-11 include provisions listed in this subsection. When the utilization
11-12 review agent receives an oral appeal of adverse determination, the
11-13 utilization review agent shall send a one-page appeal form to the
11-14 appealing party;
11-15 (3) a provision that appeal decisions shall be made by
11-16 a physician, provided that, if the appeal is denied and within 10
11-17 working days the health care provider sets forth in writing good
11-18 cause for having a particular type of a specialty provider review
11-19 the case, the denial shall be reviewed by a health care provider in
11-20 the same or similar specialty as typically manages the medical,
11-21 dental, or specialty condition, procedure, or treatment under
11-22 discussion for review of the adverse determination;
11-23 (4) in addition to the written appeal, a method for an
11-24 expedited appeal procedure for emergency care denials, denials of
11-25 care for life-threatening conditions, and denials of continued
12-1 stays for hospitalized patients. Such procedure[, which] shall
12-2 include a review by a health care provider who has not previously
12-3 reviewed the case who is of the same or a similar specialty as
12-4 typically manages the medical condition, procedure, or treatment
12-5 under review. The time frame in which[;] such appeal must be
12-6 completed shall be based on the medical or dental immediacy of the
12-7 condition, procedure, or treatment, but may in no event exceed one
12-8 working day from the date [no later than one working day following
12-9 the day on which the appeal], [including] all information necessary
12-10 to complete the appeal[,] is received [made to the utilization
12-11 review agent]; [and]
12-12 (5) a provision that after the utilization review
12-13 agent has sought review of the appeal of the adverse determination,
12-14 the utilization review agent shall issue a response letter to the
12-15 patient, a person acting on behalf of the patient, or the patient's
12-16 physician or health care provider explaining the resolution of the
12-17 appeal. Such letter shall include a statement of the specific
12-18 medical, dental, or contractual reasons for the resolution, the
12-19 clinical basis for such decision, and the specialization of any
12-20 physician or other provider consulted; and
12-21 (6) written notification to the appealing party of the
12-22 determination of the appeal, as soon as practical, but in no case
12-23 later than 30 days after the date the utilization review agent
12-24 receives the appeal [receiving all the required documentation of
12-25 the appeal. If the appeal is denied, the written notification shall
13-1 include the clinical basis for the appeal's denial and the
13-2 specialty of the physician making the denial].
13-3 SECTION 6. Section 7, Article 21.58A, Insurance Code, is
13-4 amended by adding Subsection (c) to read as follows:
13-5 (c) A utilization review agent must provide a written
13-6 description to the commissioner setting forth the procedures to be
13-7 used when responding to poststabilization care subsequent to
13-8 emergency treatment as requested by a treating physician or health
13-9 care provider.
13-10 SECTION 7. Section 8, Article 21.58A, Insurance Code, is
13-11 amended to read as follows:
13-12 Sec. 8. CONFIDENTIALITY. (a) A utilization review agent
13-13 shall preserve the confidentiality of individual medical records to
13-14 the extent required by law.
13-15 (b) A utilization review agent may not disclose or publish
13-16 individual medical records, personal information, or other
13-17 confidential information about a patient obtained in the
13-18 performance of utilization review without the prior written consent
13-19 of the patient or as otherwise required by law. If such
13-20 authorization is submitted by anyone other than the individual who
13-21 is the subject of the personal or confidential information
13-22 requested, such authorization must:
13-23 (1) be dated; and
13-24 (2) contain the signature of the individual who is the
13-25 subject of the personal or confidential information requested. The
14-1 signature must have been obtained one year or less prior to the
14-2 date the disclosure is sought or the authorization is invalid.
14-3 (c) A utilization review agent may provide confidential
14-4 information to a third party under contract or affiliated with the
14-5 utilization review agent for the sole purpose of performing or
14-6 assisting with utilization review. Information provided to third
14-7 parties shall remain confidential.
14-8 (d) If an individual submits a written request to the
14-9 utilization review agent for access to recorded personal
14-10 information about the individual, the utilization review agent
14-11 shall within 10 business days from the date such request is
14-12 received:
14-13 (1) inform the individual submitting the request of
14-14 the nature and substance of the recorded personal information in
14-15 writing; and
14-16 (2) permit the individual to see and copy, in person,
14-17 the recorded personal information pertaining to the individual or
14-18 to obtain a copy of the recorded personal information by mail, at
14-19 the discretion of the individual, unless the recorded personal
14-20 information is in coded form, in which case an accurate translation
14-21 in plain language shall be provided in writing.
14-22 (e) A utilization review agent's charges for providing a
14-23 copy of recorded personal information to individuals shall be
14-24 reasonable, as determined by rule of the commissioner, and may not
14-25 include any costs that are otherwise recouped as part of the charge
15-1 for utilization review.
15-2 (f) [(c)] The utilization review agent may not publish data
15-3 which identifies a particular physician or health care provider,
15-4 including any quality review studies or performance tracking data,
15-5 without prior written notice to the involved provider. This
15-6 prohibition does not apply to internal systems or reports used by
15-7 the utilization review agent.
15-8 (g) [(d)] Documents in the custody of the utilization review
15-9 agent that contain confidential patient information or physician or
15-10 health care provider financial data shall be destroyed by a method
15-11 which induces complete destruction of the information when the
15-12 agent determines the information is no longer needed.
15-13 (h) [(e)] All patient, physician, and health care provider
15-14 data shall be maintained by the utilization review agent in a
15-15 confidential manner which prevents unauthorized disclosure to third
15-16 parties. Nothing in this article shall be construed to allow a
15-17 utilization review agent to take actions that violate a state or
15-18 federal statute or regulation concerning confidentiality of patient
15-19 records.
15-20 (i) Notwithstanding the provisions in Subsections (a)
15-21 through (h) of this section, the utilization review agent shall
15-22 provide to the commissioner on request individual medical records
15-23 or other confidential information for determination of compliance
15-24 with this article. Such information shall be confidential and not
15-25 subject to the open records law.
16-1 SECTION 8. Subsections (a), (b), and (d), Section 9, Article
16-2 21.58A, Insurance Code, is amended to read as follows:
16-3 (a) If the commissioner believes that any person or entity
16-4 conducting utilization review pursuant to this article is in
16-5 violation of [a utilization review agent has violated or is
16-6 violating] this article or applicable regulations, the commissioner
16-7 shall notify the utilization review agent, health maintenance
16-8 organization, or insurer of the alleged violation and may compel
16-9 the production of any and all documents or other information as
16-10 necessary in order to determine whether or not such violation has
16-11 taken place [provided by this code].
16-12 (b) The commissioner may initiate the proceedings under this
16-13 section [after the 30th day after the date the commissioner
16-14 notifies the agent as required by Subsection (a) of this section].
16-15 (d) If [after notice and hearing] the commissioner
16-16 determines that the utilization review agent, health maintenance
16-17 organization, or insurer conducting utilization review pursuant to
16-18 this article has violated or is violating any provision of this
16-19 article, the commissioner may:
16-20 (1) impose sanctions under Section 7, Article 1.10 of
16-21 this code; [or]
16-22 (2) issue a cease and desist order under Article 1.10A
16-23 of this code; or
16-24 (3) assess administrative penalties under Article
16-25 1.10E of this code.
17-1 SECTION 9. Section 13, Article 21.58A, Insurance Code, is
17-2 amended to read as follows:
17-3 Sec. 13. AUTHORITY TO ADOPT RULES. The commissioner may
17-4 [board shall] have the authority to adopt rules and regulations to
17-5 implement the provisions of this article. The commissioner [board]
17-6 shall appoint an [11-member] advisory committee to advise the
17-7 commissioner [board] in developing rules and regulations to
17-8 administer this article as authorized by Section 2001.031,
17-9 Government Code. The committee's deliberations shall be subject to
17-10 the open meetings law. The committee shall include the public
17-11 counsel and one representative for each of the following:
17-12 insurance companies, health maintenance organizations, group
17-13 hospital service corporations, utilization review agents,
17-14 employers, physicians, dentists, hospitals, registered nurses, and
17-15 other health care providers.
17-16 SECTION 10. Section 14, Article 21.58A, Insurance Code, is
17-17 amended by amending Subsections (e), (g), and (h) and adding
17-18 Subsection (j) to read as follows:
17-19 (e) This article shall not apply to the terms or benefits of
17-20 employee welfare benefit plans as defined in Section 3(1) [31(I)]
17-21 of the Employee Retirement Income Security Act of 1974 (29 U.S.C.
17-22 Section 1002(1) [1002]).
17-23 (g) A health maintenance organization is not subject to this
17-24 article except as expressly provided in this subsection and
17-25 Subsection (i) of this section. If such health maintenance
18-1 organization performs utilization review as defined herein, it
18-2 shall, as a condition of licensure:
18-3 (1) comply with Sections 1, 2, 4, 5, 6, 7, 8, 9, 11,
18-4 12, 13, and 14 [4(b), (c), (e), (f), (h), (i), and (l)] of this
18-5 article, and the commissioner [board] shall promulgate rules for
18-6 appropriate verification and enforcement of compliance. However,
18-7 nothing in this article shall be construed to prohibit or limit the
18-8 distribution of a proportion of the savings from the reduction or
18-9 elimination of unnecessary medical services, treatment, supplies,
18-10 confinements, or days of confinement in a health care facility
18-11 through profit sharing, bonus, or withhold arrangements to
18-12 participating physicians or participating health care providers for
18-13 rendering health care services to enrollees; and
18-14 (2) [establish and maintain a system for:]
18-15 [(A) handling and responding to complaints by
18-16 enrollees, patients, or health care providers;]
18-17 [(B) providing health care providers with notice
18-18 of medical necessity or program requirements that have not been
18-19 met, including a reasonable opportunity to discuss the plan of
18-20 treatment and clinical basis for a utilization review determination
18-21 with a physician; and]
18-22 [(C) providing the enrollee, patient, and health
18-23 care provider an opportunity to appeal the determination; and]
18-24 [(3)] submit to assessment of maintenance taxes under
18-25 Article 20A.33, Texas Health Maintenance Organization Act (Article
19-1 20A.33, Vernon's Texas Insurance Code), to cover the costs of
19-2 administering compliance of health maintenance organizations under
19-3 this section.
19-4 (h) An insurer which delivers or issues for delivery a
19-5 health insurance policy in Texas and is subject to this code is not
19-6 subject to this article except as expressly provided in this
19-7 subsection and Subsection (i) of this section. If an insurer
19-8 performs utilization review as defined herein it shall, as a
19-9 condition of licensure, comply with Sections 1, 2, 4, 5, 6, 7, 8,
19-10 9, 11, 12, 13, and 14 [4 through 8] of this article, and the
19-11 commissioner [board] shall promulgate rules for appropriate
19-12 verification and enforcement of compliance. Such insurers shall be
19-13 subject to assessment of maintenance tax under Article 4.17 of this
19-14 code to cover the costs of administering compliance of insurers
19-15 under this section.
19-16 (j) A specialty utilization review agent is not subject to
19-17 Section 4(b), (c), (h), or (k) or Section 6(b)(3) of this article.
19-18 For purposes of this subsection, a specialty utilization review
19-19 agent means a utilization review agent that conducts utilization
19-20 review for specialty health care services, including but not
19-21 limited to dentistry, chiropractic, or physical therapy. A
19-22 specialty utilization review agent shall comply with the following
19-23 requirements:
19-24 (1) the utilization review plan, including
19-25 reconsideration and appeal requirements, shall be reviewed by a
20-1 health care provider of the appropriate specialty and conducted in
20-2 accordance with standards developed with input from a health care
20-3 provider of the appropriate specialty;
20-4 (2) personnel employed by or under contract with a
20-5 specialty utilization review agent to perform utilization review
20-6 shall be appropriately trained and qualified. Personnel who obtain
20-7 information directly from the physician or health care provider,
20-8 either orally or in writing, shall be nurses, physician assistants,
20-9 or other health care providers of the same specialty as the
20-10 utilization review agent and who are licensed or otherwise
20-11 authorized to provide the specialty health care service in this
20-12 state;
20-13 (3) utilization review conducted by a specialty
20-14 utilization review agent shall be conducted under the direction of
20-15 a health care provider of the same specialty and shall be licensed
20-16 or otherwise authorized to provide the specialty health care
20-17 service in this state;
20-18 (4) subject to the notice requirements of Section 5 of
20-19 this article, in any instance where the specialty utilization
20-20 review agent questions the medical necessity or appropriateness of
20-21 health care services, the health care provider who ordered the
20-22 services shall, prior to the issuance of an adverse determination,
20-23 be afforded a reasonable opportunity to discuss the plan of
20-24 treatment for the patient and the clinical basis for the decision
20-25 of the utilization review agent with a health care provider of the
21-1 same specialty as the utilization review agent; and
21-2 (5) appeal decisions shall be made by a physician or
21-3 health care provider in the same or a similar specialty as
21-4 typically manages the medical, dental, or specialty condition,
21-5 procedure, or treatment under discussion for review of the adverse
21-6 determination.
21-7 SECTION 11. This Act takes effect September 1, 1997.
21-8 SECTION 12. The importance of this legislation and the
21-9 crowded condition of the calendars in both houses create an
21-10 emergency and an imperative public necessity that the
21-11 constitutional rule requiring bills to be read on three several
21-12 days in each house be suspended, and this rule is hereby suspended.