33-32-103. Utilization review plan. A person may not conduct a utilization review of health care services provided or to be provided to a patient covered under a contract or plan for health care services issued in this state unless that person, at all times, maintains with the commissioner a current utilization review plan that includes:
     (1) a description of review criteria, standards, and procedures to be used in evaluating proposed or delivered health care services that, to the extent possible, must:
     (a) be based on nationally recognized criteria, standards, and procedures;
     (b) reflect community standards of care, except that a utilization review plan for health care services under the medicaid program provided for in Title 53 need not reflect community standards of care;
     (c) ensure quality of care; and
     (d) ensure access to needed health care services;
     (2) the provisions by which patients or providers may seek reconsideration or appeal of adverse decisions by the person conducting the utilization review;
     (3) the type and qualifications of the personnel either employed or under contract to perform the utilization review;
     (4) policies and procedures to ensure that a representative of the person conducting the utilization review is reasonably accessible to patients and health care providers at all times;
     (5) policies and procedures to ensure compliance with all applicable state and federal laws to protect the confidentiality of individual medical records;
     (6) a copy of the materials designed to inform applicable patients and health care providers of the requirements of the utilization review plan; and
     (7) any other information as may be required by the commissioner that is necessary to implement this chapter.

     History: En. Sec. 3, Ch. 665, L. 1991; amd. Sec. 5, Ch. 561, L. 1993.