1-1 By: Nelson, et al. S.B. No. 384
1-2 (In the Senate - Filed January 30, 1997; February 3, 1997,
1-3 read first time and referred to Committee on Economic Development;
1-4 March 3, 1997, reported adversely, with favorable Committee
1-5 Substitute by the following vote: Yeas 11, Nays 0; March 3, 1997,
1-6 sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 384 By: Cain
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to utilization review under health benefit plans and
1-11 health insurance policies.
1-12 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-13 SECTION 1. Section 2, Article 21.58A, Insurance Code, is
1-14 amended to read as follows:
1-15 Sec. 2. DEFINITIONS. In this article:
1-16 (1) "Administrative procedure act" means Chapter 2001,
1-17 Government Code [the Administrative Procedure and Texas Register
1-18 Act (Article 6252-13a, Vernon's Texas Civil Statutes)].
1-19 (2) "Administrator" means a person holding a
1-20 certificate of authority under Article 21.07-6 of this code.
1-21 (3) "Adverse determination" means a determination by a
1-22 utilization review agent that the health care services furnished or
1-23 proposed to be furnished to a patient are not medically necessary
1-24 or not appropriate in the allocation of health care resources.
1-25 (4) ["Board" means the State Board of Insurance.]
1-26 [(5)] "Certificate" means a certificate of
1-27 registration granted by the commissioner [board] to a utilization
1-28 review agent.
1-29 (5) [(6)] "Commissioner" means the commissioner of
1-30 insurance.
1-31 (6) [(7)] "Emergency care" means health care services
1-32 provided in a hospital emergency facility or comparable facility to
1-33 evaluate and stabilize medical conditions of a recent onset and
1-34 severity, including but not limited to severe pain, that would lead
1-35 a prudent layperson possessing an average knowledge of medicine and
1-36 health to believe that his or her condition, sickness, or injury is
1-37 of such a nature that failure to get immediate medical care could
1-38 result in:
1-39 (A) placing the patient's health in serious
1-40 jeopardy;
1-41 (B) serious impairment to bodily functions;
1-42 (C) serious dysfunction of any bodily organ or
1-43 part;
1-44 (D) serious disfigurement; or
1-45 (E) in the case of a pregnant woman, serious
1-46 jeopardy to the health of the fetus [bona fide emergency services
1-47 as defined in Section 2(I), Chapter 397, Acts of the 54th
1-48 Legislature, 1955 (Article 3.70-2, Vernon's Texas Insurance Code)
1-49 and Section 2(t), Texas Health Maintenance Organization Act
1-50 (Article 20A.02, Vernon's Texas Insurance Code)].
1-51 (7) [(8)] "Dental plan" means an insurance policy or
1-52 health benefit plan, including a policy written by a company
1-53 subject to Chapter 20 of this code, that provides coverage for
1-54 expenses for dental services.
1-55 (8) [(9)] "Enrollee" means a person covered by a
1-56 health insurance policy or plan and includes a person who is
1-57 covered as an eligible dependent of another person.
1-58 (9) [(10)] "Health benefit plan" means a plan of
1-59 benefits that defines the coverage provisions for health care for
1-60 enrollees offered or provided by any organization, public or
1-61 private, other than health insurance.
1-62 (10) [(11)] "Health care provider" means any person,
1-63 corporation, facility, or institution licensed by a state to
1-64 provide or otherwise lawfully providing health care services that
2-1 is eligible for independent reimbursement for those services.
2-2 (11) [(12)] "Health insurance policy" means an
2-3 insurance policy, including a policy written by a company subject
2-4 to Chapter 20 of this code, that provides coverage for medical or
2-5 surgical expenses incurred as a result of accident or sickness.
2-6 (12) "Life threatening" means diseases or conditions
2-7 where the likelihood of death is high unless the course of the
2-8 disease or condition is interrupted.
2-9 (13) "Nurse" means a professional or registered nurse,
2-10 a licensed vocational nurse, or a licensed practical nurse.
2-11 (14) "Open meetings law" means Chapter 551, Government
2-12 Code [271, Acts of the 60th Legislature, Regular Session, 1967
2-13 (Article 6252-17, Vernon's Texas Civil Statutes)].
2-14 (15) "Open records law" means Chapter 552, Government
2-15 Code [424, Acts of the 63rd Legislature, Regular Session, 1973
2-16 (Article 6252-17a, Vernon's Texas Civil Statutes)].
2-17 (16) "Patient" means the enrollee or an eligible
2-18 dependent of the enrollee under a health benefit plan or health
2-19 insurance plan.
2-20 (17) "Payor" means:
2-21 (A) an insurer writing health insurance
2-22 policies;
2-23 (B) any preferred provider organization, health
2-24 maintenance organization, self-insurance plan; or
2-25 (C) any other person or entity which provides,
2-26 offers to provide, or administers hospital, outpatient, medical, or
2-27 other health benefits to persons treated by a health care provider
2-28 in this state pursuant to any policy, plan, or contract.
2-29 (18) "Physician" means a licensed doctor of medicine
2-30 or a doctor of osteopathy.
2-31 (19) "Provider of record" means the physician or other
2-32 health care provider that has primary responsibility for the care,
2-33 treatment, and services rendered to the enrollee and includes any
2-34 health care facility when treatment is rendered on an inpatient or
2-35 outpatient basis.
2-36 (20) "Utilization review" means a system for
2-37 prospective or concurrent review of the medical necessity and
2-38 appropriateness of health care services being provided or proposed
2-39 to be provided to an individual within this state. Utilization
2-40 review shall not include elective requests for clarification of
2-41 coverage.
2-42 (21) "Utilization review agent" means an entity that
2-43 conducts utilization review for:
2-44 (A) an employer with employees in this state who
2-45 are covered under a health benefit plan or health insurance policy;
2-46 (B) a payor; or
2-47 (C) an administrator.
2-48 (22) "Utilization review plan" means the screening
2-49 criteria and utilization review procedures of a utilization review
2-50 agent.
2-51 (23) "Working day" means a weekday, excluding a legal
2-52 holiday.
2-53 SECTION 2. Subsections (b), (d), (e), and (f), Section 3,
2-54 Article 21.58A, Insurance Code, are amended to read as follows:
2-55 (b) The commissioner may only issue a certificate to an
2-56 applicant that has met all the requirements of this article and all
2-57 applicable rules and regulations of the commissioner [board].
2-58 (d) Certification may be renewed biennially by filing, not
2-59 later than March 1, a renewal form with the commissioner
2-60 accompanied by a renewal fee in an amount set by the commissioner
2-61 [board].
2-62 (e) The commissioner shall promulgate certification and
2-63 renewal forms to be filed under this section. The form for initial
2-64 certification must require the following:
2-65 (1) the entity's name, address, telephone number, and
2-66 normal business hours;
2-67 (2) the name and address of an agent for service of
2-68 process in this state;
2-69 (3) a summary of the utilization review plan, but in
3-1 no event shall proprietary details be subject to inclusion in the
3-2 summary;
3-3 (4) information concerning the personnel categories
3-4 that will perform utilization review for the utilization review
3-5 agent;
3-6 (5) a copy of the procedure established by the
3-7 utilization review agent as required by this article for appeal of
3-8 an adverse determination;
3-9 (6) a certification that the utilization review agent
3-10 will comply with the provisions of this article; and
3-11 (7) a copy of the procedures for handling oral and
3-12 written complaints by enrollees, patients, or health care
3-13 providers.
3-14 (f) The commissioner [board] shall establish, administer,
3-15 and enforce the certification and renewal fees under this section
3-16 in amounts not greater than that necessary to cover the cost of
3-17 administration of this article.
3-18 SECTION 3. Subsections (c), (h), (i), (k), (m), and (n),
3-19 Section 4, Article 21.58A, Insurance Code, are amended to read as
3-20 follows:
3-21 (c) Personnel employed by or under contract with the
3-22 utilization review agent to perform utilization review shall be
3-23 appropriately trained and qualified. Personnel who obtain
3-24 information regarding a patient's specific medical condition,
3-25 diagnosis, and treatment options or protocols directly from the
3-26 physician or health care provider, either orally or in writing, and
3-27 who are not physicians shall be nurses or[,] physician assistants.
3-28 Personnel who obtain other information directly from the physician
3-29 or health care provider, either orally or in writing, and who are
3-30 not physicians shall be nurses, physician assistants, registered
3-31 records administrators, or accredited records technicians, who are
3-32 either licensed or certified, or shall be individuals who have
3-33 received formal orientation and training in accordance with
3-34 policies and procedures established by the utilization review agent
3-35 to assure compliance with this section, and a description of such
3-36 policies and procedures shall be filed with the commissioner. This
3-37 provision shall not be interpreted to require such qualifications
3-38 for personnel who perform clerical or administrative tasks.
3-39 (h) Utilization review conducted by a utilization review
3-40 agent shall be under the direction of a physician licensed to
3-41 practice medicine in the State of Texas [by a state licensing
3-42 agency in the United States].
3-43 (i) Each utilization review agent shall utilize written
3-44 medically acceptable screening criteria and review procedures which
3-45 are established and periodically evaluated and updated with
3-46 appropriate involvement from physicians, including practicing
3-47 physicians, dentists, and other health care providers. Utilization
3-48 review decisions shall be made in accordance with currently
3-49 accepted medical or health care practices, taking into account
3-50 special circumstances of each case that may require deviation from
3-51 the norm stated in the screening criteria. Screening criteria must
3-52 be objective, clinically valid, compatible with established
3-53 principles of health care, and flexible enough to allow deviations
3-54 from the norms when justified on a case-by-case basis. Screening
3-55 criteria must be used to determine only whether to approve the
3-56 requested treatment. Denials must be referred to an appropriate
3-57 physician, dentist, or other health care provider to determine
3-58 medical necessity. Such written screening criteria and review
3-59 procedures shall be available for review and inspection to
3-60 determine appropriateness and compliance as deemed necessary by the
3-61 commissioner and copying as necessary for the commissioner to carry
3-62 out his or her lawful duties under this code, provided, however,
3-63 that any information obtained or acquired under the authority of
3-64 this subsection and article is confidential and privileged and not
3-65 subject to the open records law or subpoena except to the extent
3-66 necessary for the [board or] commissioner to enforce this article.
3-67 (k) Subject to the notice requirements of Section 5 of this
3-68 article, in any instance where the utilization review agent is
3-69 questioning the medical necessity or appropriateness of health care
4-1 services, the health care provider who ordered the services shall
4-2 be afforded a reasonable opportunity to discuss the plan of
4-3 treatment for the patient and the clinical basis for the
4-4 utilization review agent's decision with a physician [or, in the
4-5 case of a dental plan with a dentist,] prior to issuance of an
4-6 adverse determination.
4-7 (m) A utilization review agent shall establish and maintain
4-8 a complaint system that provides reasonable procedures for the
4-9 resolution of oral or written complaints initiated by enrollees,
4-10 patients, or health care providers concerning the utilization
4-11 review and shall maintain records of such [written] complaints for
4-12 three [two] years from the time the complaints are filed. The
4-13 complaint procedure shall include a written response to the
4-14 complainant by the agent within 30 [60] days. The utilization
4-15 review agent shall submit to the commissioner a summary report of
4-16 all complaints at such times and in such forms as the commissioner
4-17 [board] may require and shall permit the commissioner to examine
4-18 the complaints and all relevant documents at any time.
4-19 (n) The utilization review agent may delegate utilization
4-20 review to qualified personnel in the hospital or health care
4-21 facility where the health care services were or are to be provided.
4-22 However, such delegation shall not relieve the utilization review
4-23 agent of full responsibility for compliance with this article,
4-24 including the conduct of those to whom utilization review has been
4-25 delegated.
4-26 SECTION 4. Subsections (c) and (d), Section 5, Article
4-27 21.58A, Insurance Code, are amended to read as follows:
4-28 (c) In the event of an adverse determination, the
4-29 notification by the utilization review agent must include:
4-30 (1) the principal reasons for the adverse
4-31 determination;
4-32 (2) the clinical basis for the adverse determination;
4-33 (3) a description or the source of the screening
4-34 criteria that were utilized as guidelines in making the
4-35 determination; and
4-36 (4) [(3)] a description of the procedure for the
4-37 complaint and appeal process.
4-38 (d) The notification of adverse determination required by
4-39 this section shall be provided by the utilization review agent:
4-40 (1) within one working day by telephone or electronic
4-41 transmission to the provider of record in the case of a patient who
4-42 is hospitalized at the time of the adverse determination, to be
4-43 followed by a letter notifying the patient and the provider of
4-44 record of an adverse determination within three working days; [or]
4-45 (2) within three working days in writing to the
4-46 provider of record and the patient if the patient is not
4-47 hospitalized at the time of the adverse determination; or
4-48 (3) within the time appropriate to the circumstances
4-49 relating to the delivery of the services and the condition of the
4-50 patient, but in no case to exceed one hour from notification when
4-51 denying poststabilization care subsequent to emergency treatment as
4-52 requested by a treating physician or provider. In such
4-53 circumstances, notification shall be provided to the treating
4-54 physician or health care provider.
4-55 SECTION 5. Section 6, Article 21.58A, Insurance Code, is
4-56 amended to read as follows:
4-57 Sec. 6. APPEAL OF ADVERSE DETERMINATIONS OF UTILIZATION
4-58 REVIEW AGENTS. (a) A utilization review agent shall maintain and
4-59 make available a written description of [an] appeal procedures
4-60 involving [procedure of] an adverse determination.
4-61 (b) The procedures for appeals shall be reasonable and shall
4-62 include the following:
4-63 (1) a provision that an enrollee, a person acting on
4-64 behalf of the enrollee, or the enrollee's physician or health care
4-65 provider may appeal the adverse determination orally or in writing
4-66 [and shall be provided, on request, a clear and concise statement
4-67 of the clinical basis for the adverse determination];
4-68 (2) a provision that, within five working days from
4-69 receipt of the appeal, the utilization review agent shall send to
5-1 the appealing party a letter acknowledging the date of the
5-2 utilization review agent's receipt of the appeal and include a list
5-3 of documents needed to be submitted by the appealing party to the
5-4 utilization review agent for the appeal. Such letter must also
5-5 include provisions listed in this subsection. When the utilization
5-6 review agent receives an oral appeal of adverse determination, the
5-7 utilization review agent shall send a one-page appeal form to the
5-8 appealing party;
5-9 (3) a provision that appeal decisions shall be made by
5-10 a physician, provided that, if the appeal is denied and within 10
5-11 working days the health care provider sets forth in writing good
5-12 cause for having a particular type of a specialty provider review
5-13 the case, the denial shall be reviewed by a health care provider in
5-14 the same or similar specialty as typically manages the medical,
5-15 dental, or specialty condition, procedure, or treatment under
5-16 discussion for review of the adverse determination, and such
5-17 specialty review shall be completed within 15 working days of
5-18 receipt of the request;
5-19 (4) in addition to the written appeal, a method for an
5-20 expedited appeal procedure for emergency care denials, denials of
5-21 care for life-threatening conditions, and denials of continued
5-22 stays for hospitalized patients. Such procedure[, which] shall
5-23 include a review by a health care provider who has not previously
5-24 reviewed the case who is of the same or a similar specialty as
5-25 typically manages the medical condition, procedure, or treatment
5-26 under review. The time frame in which[;] such appeal must be
5-27 completed shall be based on the medical or dental immediacy of the
5-28 condition, procedure, or treatment, but may in no event exceed one
5-29 working day from the date [no later than one working day following
5-30 the day on which the appeal], [including] all information necessary
5-31 to complete the appeal[,] is received [made to the utilization
5-32 review agent]; [and]
5-33 (5) a provision that after the utilization review
5-34 agent has sought review of the appeal of the adverse determination,
5-35 the utilization review agent shall issue a response letter to the
5-36 patient, a person acting on behalf of the patient, or the patient's
5-37 physician or health care provider explaining the resolution of the
5-38 appeal. Such letter shall include a statement of the specific
5-39 medical, dental, or contractual reasons for the resolution, the
5-40 clinical basis for such decision, and the specialization of any
5-41 physician or other provider consulted; and
5-42 (6) written notification to the appealing party of the
5-43 determination of the appeal, as soon as practical, but in no case
5-44 later than 30 days after the date the utilization review agent
5-45 receives the appeal [receiving all the required documentation of
5-46 the appeal. If the appeal is denied, the written notification
5-47 shall include the clinical basis for the appeal's denial and the
5-48 specialty of the physician making the denial].
5-49 SECTION 6. Section 7, Article 21.58A, Insurance Code, is
5-50 amended by adding Subsection (c) to read as follows:
5-51 (c) A utilization review agent must provide a written
5-52 description to the commissioner setting forth the procedures to be
5-53 used when responding to poststabilization care subsequent to
5-54 emergency treatment as requested by a treating physician or health
5-55 care provider.
5-56 SECTION 7. Section 8, Article 21.58A, Insurance Code, is
5-57 amended to read as follows:
5-58 Sec. 8. CONFIDENTIALITY. (a) A utilization review agent
5-59 shall preserve the confidentiality of individual medical records to
5-60 the extent required by law.
5-61 (b) A utilization review agent may not disclose or publish
5-62 individual medical records, personal information, or other
5-63 confidential information about a patient obtained in the
5-64 performance of utilization review without the prior written consent
5-65 of the patient or as otherwise required by law. If such
5-66 authorization is submitted by anyone other than the individual who
5-67 is the subject of the personal or confidential information
5-68 requested, such authorization must:
5-69 (1) be dated; and
6-1 (2) contain the signature of the individual who is the
6-2 subject of the personal or confidential information requested. The
6-3 signature must have been obtained one year or less prior to the
6-4 date the disclosure is sought or the authorization is invalid.
6-5 (c) A utilization review agent may provide confidential
6-6 information to a third party under contract or affiliated with the
6-7 utilization review agent for the sole purpose of performing or
6-8 assisting with utilization review. Information provided to third
6-9 parties shall remain confidential.
6-10 (d) If an individual submits a written request to the
6-11 utilization review agent for access to recorded personal
6-12 information about the individual, the utilization review agent
6-13 shall within 10 business days from the date such request is
6-14 received:
6-15 (1) inform the individual submitting the request of
6-16 the nature and substance of the recorded personal information in
6-17 writing; and
6-18 (2) permit the individual to see and copy, in person,
6-19 the recorded personal information pertaining to the individual or
6-20 to obtain a copy of the recorded personal information by mail, at
6-21 the discretion of the individual, unless the recorded personal
6-22 information is in coded form, in which case an accurate translation
6-23 in plain language shall be provided in writing.
6-24 (e) A utilization review agent's charges for providing a
6-25 copy of recorded personal information to individuals shall be
6-26 reasonable, as determined by rule of the commissioner, and may not
6-27 include any costs that are otherwise recouped as part of the charge
6-28 for utilization review.
6-29 (f) [(c)] The utilization review agent may not publish data
6-30 which identifies a particular physician or health care provider,
6-31 including any quality review studies or performance tracking data,
6-32 without prior written notice to the involved provider. This
6-33 prohibition does not apply to internal systems or reports used by
6-34 the utilization review agent.
6-35 (g) [(d)] Documents in the custody of the utilization review
6-36 agent that contain confidential patient information or physician or
6-37 health care provider financial data shall be destroyed by a method
6-38 which induces complete destruction of the information when the
6-39 agent determines the information is no longer needed.
6-40 (h) [(e)] All patient, physician, and health care provider
6-41 data shall be maintained by the utilization review agent in a
6-42 confidential manner which prevents unauthorized disclosure to third
6-43 parties. Nothing in this article shall be construed to allow a
6-44 utilization review agent to take actions that violate a state or
6-45 federal statute or regulation concerning confidentiality of patient
6-46 records.
6-47 (i) Notwithstanding the provisions in Subsections (a)
6-48 through (h) of this section, the utilization review agent shall
6-49 provide to the commissioner on request individual medical records
6-50 or other confidential information for determination of compliance
6-51 with this article. Such information shall be confidential and not
6-52 subject to the open records law.
6-53 SECTION 8. Subsections (a), (b), and (d), Section 9, Article
6-54 21.58A, Insurance Code, is amended to read as follows:
6-55 (a) If the commissioner believes that any person or entity
6-56 conducting utilization review pursuant to this article is in
6-57 violation of [a utilization review agent has violated or is
6-58 violating] this article or applicable regulations, the commissioner
6-59 shall notify the utilization review agent, health maintenance
6-60 organization, or insurer of the alleged violation and may compel
6-61 the production of any and all documents or other information as
6-62 necessary in order to determine whether or not such violation has
6-63 taken place [provided by this code].
6-64 (b) The commissioner may initiate the proceedings under this
6-65 section [after the 30th day after the date the commissioner
6-66 notifies the agent as required by Subsection (a) of this section].
6-67 (d) If [after notice and hearing] the commissioner
6-68 determines that the utilization review agent, health maintenance
6-69 organization, or insurer conducting utilization review pursuant to
7-1 this article has violated or is violating any provision of this
7-2 article, the commissioner may:
7-3 (1) impose sanctions under Section 7, Article 1.10 of
7-4 this code; [or]
7-5 (2) issue a cease and desist order under Article 1.10A
7-6 of this code; or
7-7 (3) assess administrative penalties under Article
7-8 1.10E of this code.
7-9 SECTION 9. Section 13, Article 21.58A, Insurance Code, is
7-10 amended to read as follows:
7-11 Sec. 13. AUTHORITY TO ADOPT RULES. The commissioner may
7-12 [board shall] have the authority to adopt rules and regulations to
7-13 implement the provisions of this article. The commissioner [board]
7-14 shall appoint an [11-member] advisory committee to advise the
7-15 commissioner [board] in developing rules and regulations to
7-16 administer this article as authorized by Section 2001.031,
7-17 Government Code. The committee's deliberations shall be subject to
7-18 the open meetings law. The committee shall include the public
7-19 counsel and one representative for each of the following:
7-20 insurance companies, health maintenance organizations, group
7-21 hospital service corporations, utilization review agents,
7-22 employers, physicians, dentists, hospitals, registered nurses, and
7-23 other health care providers.
7-24 SECTION 10. Section 14, Article 21.58A, Insurance Code, is
7-25 amended by amending Subsections (e), (g), and (h) and adding
7-26 Subsection (j) to read as follows:
7-27 (e) This article shall not apply to the terms or benefits of
7-28 employee welfare benefit plans as defined in Section 3(1) [31(I)]
7-29 of the Employee Retirement Income Security Act of 1974 (29 U.S.C.
7-30 Section 1002(1) [1002]).
7-31 (g) A health maintenance organization is not subject to this
7-32 article except as expressly provided in this subsection and
7-33 Subsection (i) of this section. If such health maintenance
7-34 organization performs utilization review as defined herein, it
7-35 shall, as a condition of licensure:
7-36 (1) comply with Sections 1, 2, 4, 5, 6, 7, 8, 9, 11,
7-37 12, 13, and 14 [4(b), (c), (e), (f), (h), (i), and (l)] of this
7-38 article, and the commissioner [board] shall promulgate rules for
7-39 appropriate verification and enforcement of compliance. However,
7-40 nothing in this article shall be construed to prohibit or limit the
7-41 distribution of a proportion of the savings from the reduction or
7-42 elimination of unnecessary medical services, treatment, supplies,
7-43 confinements, or days of confinement in a health care facility
7-44 through profit sharing, bonus, or withhold arrangements to
7-45 participating physicians or participating health care providers for
7-46 rendering health care services to enrollees; and
7-47 (2) [establish and maintain a system for:]
7-48 [(A) handling and responding to complaints by
7-49 enrollees, patients, or health care providers;]
7-50 [(B) providing health care providers with notice
7-51 of medical necessity or program requirements that have not been
7-52 met, including a reasonable opportunity to discuss the plan of
7-53 treatment and clinical basis for a utilization review determination
7-54 with a physician; and]
7-55 [(C) providing the enrollee, patient, and health
7-56 care provider an opportunity to appeal the determination; and]
7-57 [(3)] submit to assessment of maintenance taxes under
7-58 Article 20A.33, Texas Health Maintenance Organization Act (Article
7-59 20A.33, Vernon's Texas Insurance Code), to cover the costs of
7-60 administering compliance of health maintenance organizations under
7-61 this section.
7-62 (h) An insurer which delivers or issues for delivery a
7-63 health insurance policy in Texas and is subject to this code is not
7-64 subject to this article except as expressly provided in this
7-65 subsection and Subsection (i) of this section. If an insurer
7-66 performs utilization review as defined herein it shall, as a
7-67 condition of licensure, comply with Sections 1, 2, 4, 5, 6, 7, 8,
7-68 9, 11, 12, 13, and 14 [4 through 8] of this article, and the
7-69 commissioner [board] shall promulgate rules for appropriate
8-1 verification and enforcement of compliance. Such insurers shall be
8-2 subject to assessment of maintenance tax under Article 4.17 of this
8-3 code to cover the costs of administering compliance of insurers
8-4 under this section.
8-5 (j) A specialty utilization review agent is not subject to
8-6 Section 4(b), (c), (h), or (k) or Section 6(b)(3) of this article.
8-7 For purposes of this subsection, a specialty utilization review
8-8 agent means a utilization review agent that conducts utilization
8-9 review for specialty health care services, including but not
8-10 limited to dentistry, chiropractic, or physical therapy. A
8-11 specialty utilization review agent shall comply with the following
8-12 requirements:
8-13 (1) the utilization review plan, including
8-14 reconsideration and appeal requirements, shall be reviewed by a
8-15 health care provider of the appropriate specialty and conducted in
8-16 accordance with standards developed with input from a health care
8-17 provider of the appropriate specialty;
8-18 (2) personnel employed by or under contract with a
8-19 specialty utilization review agent to perform utilization review
8-20 shall be appropriately trained and qualified. Personnel who obtain
8-21 information directly from the physician or health care provider,
8-22 either orally or in writing, shall be nurses, physician assistants,
8-23 or other health care providers of the same specialty as the
8-24 utilization review agent and who are licensed or otherwise
8-25 authorized to provide the specialty health care service in this
8-26 state;
8-27 (3) utilization review conducted by a specialty
8-28 utilization review agent shall be conducted under the direction of
8-29 a health care provider of the same specialty and shall be licensed
8-30 or otherwise authorized to provide the specialty health care
8-31 service in this state;
8-32 (4) subject to the notice requirements of Section 5 of
8-33 this article, in any instance where the specialty utilization
8-34 review agent questions the medical necessity or appropriateness of
8-35 health care services, the health care provider who ordered the
8-36 services shall, prior to the issuance of an adverse determination,
8-37 be afforded a reasonable opportunity to discuss the plan of
8-38 treatment for the patient and the clinical basis for the decision
8-39 of the utilization review agent with a health care provider of the
8-40 same specialty as the utilization review agent; and
8-41 (5) appeal decisions shall be made by a physician or
8-42 health care provider in the same or a similar specialty as
8-43 typically manages the medical, dental, or specialty condition,
8-44 procedure, or treatment under discussion for review of the adverse
8-45 determination.
8-46 SECTION 11. This Act takes effect September 1, 1997.
8-47 SECTION 12. The importance of this legislation and the
8-48 crowded condition of the calendars in both houses create an
8-49 emergency and an imperative public necessity that the
8-50 constitutional rule requiring bills to be read on three several
8-51 days in each house be suspended, and this rule is hereby suspended.
8-52 * * * * *