33-32-201. Conduct of utilization review. A program of utilization review with regard to health care services provided or to be provided in this state must comply with the following:
     (1) The insurer, health maintenance organization, or their agents conducting the utilization review of outpatient mental health treatment may request only information that is relevant to the payment of the claim.
     (2) When a utilization review requires disclosure of personal information regarding the patient or client, including personal and family history or current and past symptoms of a mental disorder, then the identity of that individual must be concealed from anyone having access to that information in order that the patient or client may remain anonymous.
     (3) A determination that is made on appeal or reconsideration as provided in 33-32-203 and that is adverse to a patient or to an affected health care provider may not be made on a question relating to the necessity or appropriateness of a health care service without prior written findings, evaluation, and concurrence in the adverse determination by a health care professional trained in the relevant area of health care. Copies of the written findings, evaluation, and concurrence must be provided to the patient on request as provided in Title 33, chapter 19.
     (4) A determination made on appeal or reconsideration, as provided in 33-32-203, that health care services rendered or to be rendered are medically inappropriate may not be made unless the health care professional performing the utilization review has made a reasonable attempt to consult with the patient's attending health care provider concerning the necessity or appropriateness of the health care service.
     (5) The following provisions must govern the conduct of a utilization review of health care services rendered to a patient by a health care provider who is a licensed social worker, licensed professional counselor, licensed psychiatric nurse, licensed psychiatrist, or a licensed psychologist:
     (a) If a review of the patient's or the health care provider's records is required by the insurer in the course of an appeal or a redetermination of an adverse determination of medical necessity or appropriateness made pursuant to an insurer's review, the review must be conducted by a person trained in the field of the provider.
     (b) During an appeal or redetermination, the patient may, at the patient's expense, request an independent review of the patient's or the provider's records by a health care provider licensed in the field of the provider that rendered the health care service and may require that review to be considered by the insurer in reaching its decision. If the initial adverse determination of medical necessity or appropriateness is reversed, the insurer shall bear the expense of the independent review.

     History: En. Sec. 4, Ch. 665, L. 1991; amd. Sec. 1, Ch. 378, L. 1993.