ROBERT L. EHRLICH, JR., Governor                             Ch. 415

[(m)] (N) "Utilisation review" means a system for reviewing the appropriate
and efficient allocation of health care resources and services given or proposed to be
given to a patient or group of patients.

[(n)] (O) "Utilization review plan" means a description of the standards
governing utilization review activities performed by a private review agent.

15-10B-06.

(a)     [(1)] 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.] SHALL PROVIDE NOTICE OF ALL
DETERMINATIONS TO THE PATIENT AND THE AUTHORIZED REPRESENTATIVE,
WHETHER ADVERSE OR NOT, WITHIN THE TIME PERIODS SPECIFIED IN § 15-10A-02(I)
OF THIS TITLE.

(b)     [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 determination, by telephone on an expedited basis, within a period of
time not to exceed 24 hours of the health care provider seeking the reconsideration.

(e)] For emergency inpatient admissions, a private review agent may not
render an adverse decision solely because the hospital did not notify the private
review agent of the emergency admission within 24 hours or other prescribed period
of time after that admission if the patient's medical condition prevented the hospital
from determining:

(1) the patient's insurance status; and

(2) if applicable, the private review agent's emergency admission
notification requirements.

[(d)] (C) A private review agent may not render an adverse decision as to an
admission of a patient during the first 24 hours after admission when:

(1) the admission is based on a determination that the patient is in
imminent danger to self or others;

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