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ROBERT L. EHRLICH, JR., Governor
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Ch. 331
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[(10)] (11) certification by the private review agent that the criteria and
standards to be used in conducting utilization review are:
(i) objective;
(ii) clinically valid;
(iii) compatible with established principles of health care; and
(iv) flexible enough to allow deviations from norms when justified
on a case by case basis.
15-10B-06.
(a) (1) [A] EXCEPT AS PROVIDED IN PARAGRAPH (3) OF THIS SUBSECTION,
A private review agent shall:
(i) make all initial determinations on whether to authorize or
certify a nonemergency course of treatment for a patient within 2 working days after
receipt of the information necessary to make the determination;
(ii) make all determinations on whether to authorize or certify an
extended stay in a health care facility or additional health care services within 1
working day after receipt of the information necessary to make the determination;
and
(iii) promptly notify the health care provider of the determination.
(2) If within 3 calendar days after receipt of the initial request for health
care services the private review agent does not have sufficient information to make a
determination, the private review agent shall inform the health care provider that
additional information must be provided.
(3) IF A PRIVATE REVIEW AGENT REQUIRES PRIOR AUTHORIZATION FOR
AN EMERGENCY INPATIENT ADMISSION. OR AN ADMISSION FOR RESIDENTIAL CRISIS
SERVICES AS DEFINED IN § 15-840 OF THIS TITLE. FOR THE TREATMENT OF A
MENTAL, EMOTIONAL, OR SUBSTANCE ABUSE DISORDER, A THE PRIVATE REVIEW
AGENT SHALL:
(I) MAKE ALL DETERMINATIONS ON WHETHER TO AUTHORIZE OR
CERTIFY AN INPATIENT ADMISSION. OR AN ADMISSION FOR RESIDENTIAL CRISIS
SERVICES AS DEFINED IN § 15-840 OF THIS TITLE. WITHIN 2 HOURS AFTER RECEIPT
OF THE INFORMATION NECESSARY TO MAKE THE DETERMINATION; AND
(II) PROMPTLY NOTIFY THE HEALTH CARE PROVIDER OF THE
DETERMINATION.
(b) (1) [If] EXCEPT AS PROVIDED IN PARAGRAPH (3) OF THIS SUBSECTION,
IF an initial determination is made by a private review agent not to authorize or
certify a health care service and the health care provider believes the determination
warrants an immediate reconsideration, a private review agent may provide the
health care provider the opportunity to speak with the physician that rendered the
- 1789 -
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