33-32-103: Utilization review plan.

An entity covered under the provisions of this chapter 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 entity, at all times, maintains and can provide at the commissioner's request 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) policies and procedures to ensure that a representative of the entity conducting the utilization review is reasonably accessible to patients and health care providers at all times;

(3) policies and procedures to ensure compliance with all applicable state and federal laws to protect the confidentiality of individual medical records;

(4) a copy of the materials designed to inform applicable patients and health care providers of the requirements of the utilization review plan; and

(5) any other information that may be required by the commissioner that is necessary to implement this chapter.