Current through Register Vol. XLI, No. 38, September 20, 2024
6.1. A
prepaid limited health service organization shall have a documented utilization
management program which 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
limited health services.
a. The UM program shall have a mechanism for
evaluating and updating the program description on a periodic basis which shall be
specified by the prepaid limited health service organization.
6.2. The UM program shall have written utilization
review decision protocols based on reasonable medical evidence.
a. A prepaid limited health service organization
shall have criteria for appropriateness of a limited health service clearly
documented and available, upon request, to participating physicians.
b. A prepaid limited health service organization
shall establish a mechanism for checking the consistency of the application of
criteria utilized by reviewers.
c. A
prepaid limited health service organization shall establish a mechanism for updating
review criteria on a periodic basis which shall be specified by the prepaid limited
health service organization.
6.3. The UM program shall have professionally
accepted, pre-established criteria for the preauthorization of services and for
concurrent review of admissions.
a. A prepaid
limited health service organization shall, on a timely basis, make efforts to obtain
all necessary information, including pertinent clinical information, and
consultation with the treating provider, as appropriate.
b. Qualified medical professionals shall review
decisions for preauthorization of limited health services and concurrent review of
admissions.
c. A duly licensed physician
shall conduct a review of medical appropriateness on any denial of limited health
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 limited health services whenever
necessary.
6.4. Decisions
regarding provision of limited health services shall be made in a timely manner
depending upon the urgency of the situation.
a.
The prepaid limited health service organization shall establish medically
appropriate time frames for urgent, emergency and planned care cases.
b. In those instances in which a prepaid limited
health service organization denies limited health 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 coordinating provider, and the facility, if
appropriate.
1. The written notice of denial shall
include the reason for denial and an explanation of the appeal process.
6.5. A prepaid limited
health service organization may have policies and procedures in place to evaluate
the appropriate use of new medical technologies, or new application 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, 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.
6.6. A prepaid limited health service organization
shall have mechanisms to evaluate the effects of the program using member
satisfaction data, provider satisfaction data and other appropriate means.
