Chapter 17C - Standards For Managed Care Plans
- Section 58-17C-1 - Definitions.
- Section 58-17C-2 - Medical director required for managed care plans.
- Section 58-17C-3 - Applicability of § 58-17C-2.
- Section 58-17C-4 - Applicability of 58-17C-4 and 58-17C-6.
- Section 58-17C-5 - Health carrier to provide written information to prospective enrollees--Specific information required.
- Section 58-17C-6 - Certain plans exempt from requirement of written information.
- Section 58-17C-7 - Applicability of §§ 58-17C-7 to 58-17C-26, inclusive.
- Section 58-17C-8 - Health carrier to maintain provider network sufficient to assure serviceswithout unreasonable delay--Emergency services--Determination ofsufficiency.
- Section 58-17C-9 - Where provider network is insufficient, covered benefit to be madeavailable at no greater cost.
- Section 58-17C-10 - Health carrier to ensure provider proximity to covered persons.
- Section 58-17C-11 - Health carrier to monitor provider ability, capacity, and authority--Financial capability to be monitored in capitated plans.
- Section 58-17C-12 - Factors to be considered in determining network adequacy.
- Section 58-17C-13 - Access plan required for managed care plans--Annual update--Contents--Discounted fee-for-service networks exempt.
- Section 58-17C-14 - Requirements for health carrier offering managed care plan.
- Section 58-17C-15 - Provisions governing contractual arrangements between health carriers andintermediaries.
- Section 58-17C-16 - Sample contract forms to be filed with director--Material changes to besubmitted to director--Certain changes not material--Director's inactionwithin certain time deemed approv
- Section 58-17C-17 - Contract does not relieve health carrier of liability.
- Section 58-17C-18 - Remedies available to director against health carrier found not incompliance.
- Section 58-17C-19 - Director authorized to promulgate rules--Scope of rules.
- Section 58-17C-20 - Managed care contractors to register with director.
- Section 58-17C-21 - Health carrier to develop and maintain systems to measure quality ofservices--System requirements--Description of quality assessment programto be filed with director.
- Section 58-17C-22 - Health carrier issuing closed plan to develop quality improvementactivities--Minimum requirements of quality improvement activities.
- Section 58-17C-23 - Certain plans exempt from §§ 58-17C-7 to 58-17C-26, inclusive.
- Section 58-17C-24 - If private accrediting body satisfies requirements of §§ 58-17C-7 to 58-17C-26, inclusive, carrier may be deemed to have done so.
- Section 58-17C-25 - Health carriers offering individual policies exempt--Conditions.
- Section 58-17C-26 - Division of Insurance to monitor complaints against individual policies.
- Section 58-17C-27 - Health carrier to provide emergency services coverage without requiringprior authorization--Standards for determining whether emergency medicalcondition exists--Level of coverage.
- Section 58-17C-28 - Health carrier not to subsequently retract authorization after item orservice provided in reliance on authorization--Exceptions.
- Sections 58-17C-29, 58-17C-30 - Emergency services coverage subject to limitations. Access to representative for post-evaluation or post-stabilization services
- Section 58-17C-31 - Access to emergency medical services.
- Section 58-17C-32 - Certain plans exempt from emergency medical service provisions.
- Section 58-17C-33 - If private accrediting body meets emergency medical coveragerequirements, health carrier may be deemed to have done so.
- Section 58-17C-34 - Applicability of chapter 17C.
- Section 58-17C-35 - Health carrier responsibility for utilization review activities.
- Section 58-17C-36 - Director to hold health carrier responsible for utilization reviewperformance of contractor.
- Section 58-17C-37 - Written utilization review program required--Contents of programdocument.
- Section 58-17C-38 - Utilization review program to use documented clinical review criteria--Criteria to be made available to authorized agencies upon request.
- Section 58-17C-39 - Program to be administered by qualified licensed health care professionals.
- Section 58-17C-40 - Determinations to be issued in a timely manner--Process to ensureconsistency.
- Section 58-17C-40.1 - Calculation of time period for determination for prospective andretrospective reviews.
- Section 58-17C-41 - Effectiveness and efficiency of program to be routinely reviewed.
- Section 58-17C-42 - Data systems must support program activities and generate managementreports.
- Section 58-17C-43 - Health carrier oversight of delegated activities--Requirements.
- Section 58-17C-44 - Utilization review to be coordinated with other medical managementactivity of health carrier.
- Section 58-17C-45 - Health carrier to provide free access to review staff.
- Section 58-17C-46 - Only information necessary for review or determination to be collected.
- Section 58-17C-47 - Prohibition against compensation influencing or based upon reviewdecisions.
- Section 58-17C-48 - Written procedures required for making determinations--Notification.
- Section 58-17C-49 - Prospective review determinations--Timing--Notification of requirements--Extension of time.
- Section 58-17C-50 - Concurrent review determinations--Timing--Notification requirements.
- Section 58-17C-51 - Retrospective review determinations--Timing--Notification requirements.
- Section 58-17C-52 - Notification of adverse determination--Contents.
- Section 58-17C-53 - Repealed.
- Section 58-17C-54 - Information required to be provided to covered persons and prospectivecovered persons.
- Section 58-17C-55 - Certain plans exempt from requirements of §§ 58-17C-34 to 58-17C-57,inclusive.
- Section 58-17C-56 - If private accrediting body meets requirements, health carrier may bedeemed to have met them.
- Section 58-17C-57 - Director authorized to promulgate rules--Scope of rules.
- Section 58-17C-58 - Establishment of grievance system by managed care plan or utilizationreview organization.
- Section 58-17C-59 - Record of grievances--Report.
- Section 58-17C-60 - Maintenance of grievance records--Accessibility.
- Sections 58-17C-61, 58-17C-62 - Repealed
- Section 58-17C-63 - Promulgation of rules for grievance system.
- Section 58-17C-64 - Registration of utilization review organizations--Required information.
- Sections 58-17C-65, 58-17C-66 - Filing changes in registration information. Requests of information from utilization review organizations
- Section 58-17C-67 - Activities of nonregistered utilization review organizations prohibited.
- Section 58-17C-68 - Registration fee for utilization review organizations.
- Section 58-17C-69 - Application of §§ 58-17C-58 to 58-17C-68, inclusive.
- Section 58-17C-70 - "Urgent care request" defined.
- Section 58-17C-71 - Urgent care requests--Written procedures for receipt and determination ofrequests required.
- Section 58-17C-72 - Urgent care requests--Timely notification of determination.
- Section 58-17C-73 - Insufficient information for determination--Notice and statement ofnecessary information required.
- Section 58-17C-74 - Insufficient information for determination of prospective urgent carerequests.
- Section 58-17C-75 - Time within which to submit necessary information.
- Section 58-17C-76 - Urgent care requests--Notice of determination--Failure to submit necessaryinformation grounds for denial of certification--Notice of adversedeterminations.
- Section 58-17C-77 - Concurrent review urgent care requests--Requests for extended care--Timeto make determination and provide notice.
- Section 58-17C-78 - Calculation of time periods for determinations.
- Section 58-17C-79 - Notification of adverse determinations--Requirements.
- Section 58-17C-80 - Register of grievances required--Information to be compiled--Maintenance.
- Section 58-17C-81 - Report to director required--Contents of report.
- Section 58-17C-82 - Grievance procedures--Filing with director required--Certificate ofcompliance--Contact information required.
- Section 58-17C-83 - Review of adverse determinations--Time for filing--Designation andnotice of reviewers--Scope of review.
- Section 58-17C-84 - Review of adverse determinations--Rights of covered person or authorizedrepresentative--Access to documentation.
- Section 58-17C-85 - Review of adverse determinations--Time for issuing decisions andproviding notice--Calculation of time periods.
- Section 58-17C-86 - Issuance of decision--Required contents.
- Section 58-17C-87 - Health carrier to establish review procedures for grievances not involvingadverse determinations.
- Section 58-17C-88 - Standard review--Covered persons or authorized representatives entitledto submit written material only.
- Section 58-17C-89 - Designation of person(s) to conduct standard review--Notice to coveredperson or authorized representative.
- Section 58-17C-90 - Standard review--Time within which to notify covered person of decision--Extension of time.
- Section 58-17C-91 - Standard review--Required contents of written decision.
- Section 58-17C-92 - Additional voluntary review--Right of covered person to appear--Requirednotice--Not applicable to health indemnity plans.
- Section 58-17C-93 - Additional voluntary review--Required notice--Rights of coveredperson(s) or authorized representatives.
- Section 58-17C-94 - Appointment of panel for voluntary review of first level review decision--Scope of review--Composition of panel.
- Section 58-17C-95 - Standard review--Appointment of voluntary review panel--Compositionof panel.
- Section 58-17C-96 - Procedures for appearance before voluntary review panel--Legalrepresentation--Time for issuance of decision.
- Section 58-17C-97 - Notice and issuance of decision when covered person does not requestappearance--Time for issuance of decision.
- Section 58-17C-98 - Decision by voluntary review panel--Required contents.
- Section 58-17C-99 - Expedited review for adverse determinations involving urgent carerequests--Appointment of peers for review.
- Section 58-17C-100 - Expedited review not initial determination for benefits--Transmission ofnecessary information.
- Section 58-17C-101 - Expedited review decision not initial determination for benefits--Time ofnotification--Continuation of service involving concurrent review urgentcare requests.
- Section 58-17C-102 - Expedited review decision--Notification--Required contents.
- Section 58-17C-102.1 - Applicability of §§ 58-17C-40 to 58-17C-102, inclusive.
- Section 58-17C-103 - Promulgation of rules--Consistency with federal requirements.
- Section 58-17C-104 - Transferred.
- Section 58-17C-105 - Transferred.
- Section 58-17C-106 - Transferred.
- Section 58-17C-107 - Transferred.