Current through Register Vol. XLI, No. 38, September 20, 2024
4.1. A health maintenance organization shall
develop a utilization management (UM) program which adheres to all applicable state
and federal laws, federal regulations and state rules.
4.2. Each application for a certificate of
authority or renewal thereof filed with the commissioner pursuant to the Health
Maintenance Organization Act, W. Va. Code '
33-25A-1 et
seq., shall be accompanied by a description of the health maintenance organization's
utilization management program, which shall include, but not be limited to, the
requirements of the utilization management program set forth in this rule.
a. Pursuant to the requirements of W. Va. Code
'33-25A-3,
a health maintenance organization shall file notice with the commissioner prior to
any modification of the utilization management program.
4.3. A health maintenance organization shall have
a documented utilization management program description that describes both
delegated and non-delegated activities.
a. The UM
program description shall include, at a minimum, performance goals, policies and
procedures to evaluate medical necessity, criteria used, information sources, and
the process used to review and approve the provision of medical services.
b. The UM program shall have a mechanism for
evaluating and updating the program description on a periodic basis which shall be
specified by the health maintenance organization.
4.4. If a health maintenance organization
delegates any UM activities to contractors, there shall be evidence of oversight of
the contracted entity.
a. The health maintenance
organization shall maintain a written description of:
1. The delegated activities;
2. The contractor's accountability for these
activities;
3. The frequency of
reporting to the health maintenance organization; and
4. The process by which the delegation will be
evaluated.
b. The health
maintenance organization shall maintain evidence of:
1. Approval of the contractor's UM program;
and
2. Evaluation of regular UM reports
from the contractor.
c. The
health maintenance organization shall be responsible for monitoring the activities
of the entity to which it delegates UM activities and for ensuring that the
requirements of this rule are met.
4.5. Each health maintenance organization shall
have written procedures for assuring that patient-specific information obtained
during any UM activity will be:
a. Kept
confidential in accordance with applicable federal and state laws; and
b. Used solely for the purposes of utilization
management, in addition to quality assurance, discharge planning and catastrophic
case management.
4.6. The UM
program shall have written utilization review decision protocols based on reasonable
medical evidence.
a. A health maintenance
organization shall have criteria for appropriateness of medical services clearly
documented and available, upon request, to participating physicians.
b. A health maintenance organization shall
establish a mechanism for checking the consistency of the application of criteria
utilized by reviewers.
c. A health
maintenance organization shall establish a mechanism for updating review criteria on
a periodic basis which shall be specified by the health maintenance
organization.
4.7. The UM
program shall have professionally accepted, pre-established criteria for the
preauthorization of services and for concurrent review of admissions.
a. A health maintenance organization shall, on a
timely basis, make efforts to obtain all necessary information, including pertinent
clinical information, and consultation with the treating physician, as
appropriate.
b. Qualified medical
professionals shall review decisions for preauthorization of medical services and
concurrent review of admissions.
c. A
duly licensed physician shall conduct a review of medical appropriateness on any
denial of medical services.
d. At any
point during the review process, a licensed physician consultant specially trained
in the area of medicine in question shall be available to provide his or her expert
opinion regarding medical appropriateness and necessity of medical services whenever
necessary.
4.8. Decisions
regarding provision of medical services shall be made in a timely manner depending
upon the urgency of the situation.
a. The health
maintenance organization shall establish medically appropriate time frames for
urgent, emergency and planned care cases.
b. In those instances in which a health
maintenance organization denies medical services, a written notice of denial shall
be sent immediately to all involved parties, which shall include, but not be limited
to, the subscriber, the primary care physician, and the facility, if appropriate.
1. The written notice of denial shall include the
reason for denial and an explanation of the appeal process.
4.9. A health maintenance organization
may have policies and procedures in place to evaluate the appropriate use of new
medical technologies, or new applications of established technologies, including
medical procedures, drugs, and devices. Any policies and procedures in place
regarding new medical technologies shall include standards requiring:
a. Appropriate professionals to participate in the
development of technology evaluation criteria;
b. The review of information from appropriate
health-related government agencies and/or government regulatory bodies and published
scientific evidence;
c. Assessment of
new technologies and new applications of existing technologies; and
d. Periodic evaluation and update of policies and
procedures as technologies and procedures expand and change.
4.10. A health maintenance organization shall have
mechanisms to evaluate the effects of the program using member satisfaction data,
provider satisfaction data, and/or other appropriate means.
