|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S.B. 190
|
|
VETOES
|
|
|
|
|
|
|
|
|
|
(i) the specific criteria and standards to be used in conducting
utilization review of proposed or delivered HEALTH CARE services;
(ii) those circumstances, if any, under which utilization review may
be delegated to a hospital utilization review program; and
(iii) [the] IF APPLICABLE, ANY provisions by which patients,
physicians, or hospitals may seek reconsideration [or appeal of adverse decisions by
the private review agent];
(2) the type and qualifications of the personnel either employed or under
contract to perform the utilization review;
(3) A COPY OF THE PRIVATE REVIEW AGENT'S INTERNAL GRIEVANCE
PROCESS IF A CARRIER DELEGATES ITS INTERNAL GRIEVANCE PROCESS TO THE
PRIVATE REVIEW AGENT IN ACCORDANCE WITH § 15-10A-02(L) OF THIS TITLE;
[(3)] (4) the procedures and policies to ensure that a representative of
the private review agent is reasonably accessible to patients and HEALTH CARE
providers [5] 7 days a week [during normal business], 24 hours A DAY in this State;
[(4)] (5) the policies and procedures to ensure that all applicable State
and federal laws to protect the confidentiality of individual medical records are
followed;
[(5)] (6) a copy of the materials designed to inform applicable patients
and providers of the requirements of the utilization review plan;
[(6)] (7) a list of the third party payors for which the private review
agent is performing utilization review in this State;
[(7)] (8) the policies and procedures to ensure that the private review
agent has a formal program for the orientation and training of the personnel either
employed or under contract to perform the utilization review;
[(8)] (9) a list of the health care providers AS DEFINED IN § 15-10B-07 OF
THIS SUBTITLE PERSONS involved in establishing the specific criteria and standards
to be used in conducting utilization review; and
[(9)] (10) 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.
(b) (1) At least [10] 30 days before a private review, agent requires any
revisions or modifications to [the] EXISTING specific criteria and standards to be
|
|
|
|
|
|
|
|
|
|
- 3756 -
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
