376.1361. Documented clinical review criteria used in a utilization program--medical director qualifications--compensation of utilization review services.
Documented clinical review criteria used in a utilizationprogram--medical director qualifications--compensation ofutilization review services.
376.1361. 1. A utilization review program shall use documented clinicalreview criteria that are based on sound clinical evidence and are evaluatedperiodically to assure ongoing efficacy. A health carrier may develop its ownclinical review criteria, or it may purchase or license clinical reviewcriteria from qualified vendors. A health carrier shall make available itsclinical review criteria upon request by either the director of the departmentof health and senior services or the director of the department of insurance,financial institutions and professional registration.
2. Any medical director who administers the utilization review programor oversees the review decisions shall be a qualified health care professionallicensed in the state of Missouri. A licensed clinical peer shall evaluatethe clinical appropriateness of adverse determinations.
3. A health carrier shall issue utilization review decisions in a timelymanner pursuant to the requirements of sections 376.1363, 376.1365 and376.1367. A health carrier shall obtain all information required to make autilization review decision, including pertinent clinical information. Ahealth carrier shall have a process to ensure that utilization reviewers applyclinical review criteria consistently.
4. A health carrier's data systems shall be sufficient to supportutilization review program activities and to generate management reports toenable the health carrier to monitor and manage health care serviceseffectively.
5. If a health carrier delegates any utilization review activities to autilization review organization, the health carrier shall maintain adequateoversight, which shall include:
(1) A written description of the utilization review organization'sactivities and responsibilities, including reporting requirements;
(2) Evidence of formal approval of the utilization review organizationprogram by the health carrier; and
(3) A process by which the health carrier evaluates the performance ofthe utilization review organization.
6. The health carrier shall coordinate the utilization review programwith other medical management activities conducted by the carrier, such asquality assurance, credentialing, provider contracting, data reporting,grievance procedures, processes for accessing member satisfaction and riskmanagement.
7. A health carrier shall provide enrollees and participating providerswith timely access to its review staff by a toll-free number.
8. When conducting utilization review, the health carrier shall collectonly the information necessary to certify the admission, procedure ortreatment, length of stay, frequency and duration of services.
9. Compensation to persons providing utilization review services for ahealth carrier shall not contain direct or indirect incentives for suchpersons to make medically inappropriate review decisions. Compensation to anysuch persons may not be directly or indirectly based on the quantity or typeof adverse determinations rendered.
10. A health carrier shall permit enrollees or a provider on behalf ofan enrollee to appeal for the coverage of medically necessary pharmaceuticalprescriptions and durable medical equipment as part of the health carriers'utilization review process.
11. (1) This subsection shall apply to:
(a) Any health benefit plan that is issued, amended, delivered orrenewed on or after January 1, 1998, and provides coverage for drugs; or
(b) Any person making a determination regarding payment or reimbursementfor a prescription drug pursuant to such plan.
(2) A health benefit plan that provides coverage for drugs shall providecoverage for any drug prescribed to treat an indication so long as the drughas been approved by the FDA for at least one indication, if the drug isrecognized for treatment of the covered indication in one of the standardreference compendia or in substantially accepted peer-reviewed medicalliterature and deemed medically appropriate.
(3) This section shall not be construed to require coverage for a drugwhen the FDA has determined its use to be contraindicated for treatment of thecurrent indication.
(4) A drug use that is covered pursuant to subsection 1 of this sectionshall not be denied coverage based on a "medical necessity" requirement exceptfor a reason that is unrelated to the legal status of the drug use.
(5) Any drug or service furnished in a research trial, if the sponsor ofthe research trial furnishes such drug or service without charge to anyparticipant in the research trial, shall not be subject to coverage pursuantto subsection 1 of this section.
(6) Nothing in this section shall require payment for nonformularydrugs, except that the state may exclude or otherwise restrict coverage of acovered outpatient drug from Medicaid programs as specified in the SocialSecurity Act, Section 1927(d)(1)(B).
12. A carrier shall issue a confirmation number to an enrollee when thehealth carrier, acting through a participating provider or other authorizedrepresentative, authorizes the provision of health care services.
13. If an authorized representative of a health carrier authorizes theprovision of health care services, the health carrier shall not subsequentlyretract 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 oromission about the treated person's health condition or the cause of thehealth condition; or
(2) The health benefit plan terminates before the health care servicesare provided; or
(3) The covered person's coverage under the health benefit planterminates before the health care services are provided.
(L. 1997 H.B. 335)