§ 23-17.12-5 - General application requirements.
SECTION 23-17.12-5
§ 23-17.12-5 General applicationrequirements. – An application for certification or recertification shall be accompanied bydocumentation to evidence the following:
(1) The requirement that the review agent provide patientsand providers with a summary of its utilization review plan including a summaryof the standards, procedures and methods to be used in evaluating proposed ordelivered health care services;
(2) The circumstances, if any, under which utilization reviewmay be delegated to any other utilization review program and evidence that thedelegated agency is a certified utilization review agency delegated to performutilization review pursuant to all of the requirements of this chapter;
(3) A complaint resolution process consistent with subsection23-17.12-2(6) and acceptable to the department, whereby patients, theirphysicians, or other health care providers may seek resolution of complaintsand other matters of which the review agent has received written notice;
(4) The type and qualifications of personnel (employed orunder contract) authorized to perform utilization review, including arequirement that only a practitioner with the same license status as theordering practitioner, or a licensed physician or dentist, is permitted to makea prospective or concurrent adverse determination;
(5) The requirement that a representative of the review agentis reasonably accessible to patients, patient's family and providers at leastfive (5) days a week during normal business in Rhode Island and during thehours of the agency's review operations;
(6) The policies and procedures to ensure that all applicablestate and federal laws to protect the confidentiality of individual medicalrecords are followed;
(7) The policies and procedures regarding the notificationand conduct of patient interviews by the review agent;
(8) The requirement that no employee of, or other individualrendering an adverse determination for, a review agent may receive anyfinancial incentives based upon the number of denials of certification made bythat employee or individual;
(9) The requirement that the utilization review agent shallnot impede the provision of health care services for treatment and/orhospitalization or other use of a provider's services or facilities for anypatient;
(10) Evidence that the review agent has not entered into acompensation agreement or contract with its employees or agents whereby thecompensation of its employees or its agents is based upon a reduction ofservices or the charges for those services, the reduction of length of stay, orutilization of alternative treatment settings; provided, nothing in thischapter shall prohibit agreements and similar arrangements; and
(11) An adverse determination and internal appeals processconsistent with § 23-17.12-9 and acceptable to the department, wherebypatients, their physicians, or other health care providers may seek promptreconsideration or appeal of adverse determinations by the review agent.