Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This amendment modifies the purpose
statement appearing in the Code of State Regulations to more accurately reflect
the content of the rule. The amendment also reformats filing and other
requirements, clarifies that late renewal penalties are discretionary, and
removes a restriction limiting registered entities to the use of one (1)
fictitious name.
PURPOSE: This rule sets forth the procedure for a
utilization review agent to obtain and maintain a certificate of registration,
and establishes fees and forms pursuant to the requirements of section
374.505,
RSMo. The rule also clarifies the standards applicable to utilization review
agents conducting utilization review in this state.
(1) Pursuant to the requirements of section
374.505,
RSMo, each application for a certificate of registration as a utilization
review agent shall:
(A) Be submitted to the
department on a form provided by the department;
(B) Be signed by the applicant or, if the
applicant is a corporation, by an officer or, if the applicant is a
partnership, by one (1) of the partners;
(C) Be accompanied by an initial registration
fee of one thousand dollars ($1,000);
(D) Disclose all fictitious names under which
the applicant entity will operate as a utilization review agent in this state;
and
(E) Provide any other
reasonably related supporting documentation necessary to process the
utilization review agent's registration.
(2) Each recipient of a certificate of
registration may maintain their registration by filing for renewal annually on
or before the anniversary date of the initial certificate as shown on the
original certification. Each application for renewal shall-
(A) Be submitted on a form provided by the
department;
(B) Be accompanied by a
renewal fee of five hundred dollars ($500);
(C) Be accompanied by a list of the
utilization review agent's current health plan clients with contact information
for each such health plan client. A list of the health plan's clients is not
necessary;
(D) Disclose all
fictitious names under which the applicant entity has and will operate as a
utilization review agent in this state; and
(E) Provide any other reasonably related
supporting documentation necessary to maintain the utilization review agent's
registration.
(3) Failure
to renew a certificate of registration may result in a fine as set forth in
section
374.280,
RSMo.
(4) Pursuant to sections
374.046
and
374.512,
RSMo, the director may take action against any utilization review agent doing
business in this state without a certificate of registration in violation of
section
374.503,
RSMo, even if the principal place of business of the utilization review agent
is located in another state.
(5)
Any utilization review agent doing business in this state under a name other
than its true name shall file with the director a copy of all documents,
including the authorization from the Missouri Secretary of State which shows
the legal authority for the utilization review agent to use such other
name.
(6) Pursuant to section
374.510,
RSMo, the minimum requirements of sections
376.1350 to
376.1399,
RSMo, as applied to utilization review agents include, but are not limited to,
the following:
(A) That any medical director
who administers the utilization review program or oversees the review decisions
be a qualified health care professional licensed in the state of
Missouri;
(B) That a licensed
clinical peer evaluate the clinical appropriateness of adverse
determinations;
(C) That
utilization review decisions be made and issued in a timely manner pursuant to
the requirements of sections
376.1363,
376.1365,
and
376.1367,
RSMo;
(D) That a utilization
review agent provide health plan enrollees and health plan participating
providers with timely access to its review staff by a toll-free
number;
(E) That when conducting
utilization review, the utilization review agent shall collect only the
information necessary to certify the admission, procedure or treatment, length
of stay, frequency, and duration of services and not require or request a
Federal Drug Enforcement Administration Number or a Missouri Controlled
Substance Registration Number from any provider;
(F) That compensation to persons providing utilization
review services for a utilization review agent not contain direct or indirect
incentives for such persons to make medically inappropriate review decisions or
be directly or indirectly based on the quantity or type of adverse
determinations rendered;
(G) That
a utilization review agent responsible for pre-approving any covered benefits
or services issue a confirmation number to the enrollee when it authorizes the
provision of health care services; and
(H) That if a utilization review agent authorizes the
provision of health care services, the utilization review agent not
subsequently retract its authorization after the health care services have been
provided, or reduce payment for an item or service furnished in reliance on
approval, unless-
1. Such authorization is
based on a material misrepresentation or omission about the treated person's
health condition or the cause of the health condition; or
2. The health benefit plan terminates before
the health care services are provided; or
3. The covered person's coverage under the
health benefit plan terminates before the health care services are
provided.
*Original authority 374.515, RSMo 1991, amended 1993 and
376.1399, RSMo 1997, amended 1997, 2007.
