59A-47-60: Utilization review of mental health or substance use disorder services.

A. A health care plan shall, at least monthly, review and update the health care plan's utilization review process to reflect the most recent evidence and generally recognized standards of care.

B. When performing a utilization review of mental health or substance use disorder services, including level of care placement, continued stay, transfer and discharge, a health care plan shall apply criteria in accordance with generally recognized standards of care.

C. A health care plan shall provide utilization review training to staff and contractors undertaking activities related to utilization review.

D. A health care plan shall:

(1) develop utilization review policies regarding quantitative and non-quantitative limitations for mental health or substance use disorder services coverage that are no more restrictive than the utilization review policies regarding quantitative and non-quantitative limitations for medical and surgical care; and

(2) make utilization review policies available to providers or subscribers.