760 IAC 1-46-3 - Certification of utilization review agents
Authority: IC 27-8-17-20
Affected: IC 4-21.5; IC 27-8-17-19
Sec. 3.
(a) An
application for certification of a utilization review agent must be filed with
the department of insurance at 311 West Washington Street, Suite 300,
Indianapolis, Indiana 46204. Initial applications must be filed on or before
February 28, 1993.
(b) The
application must be submitted on a utilization review agent application form
that can be obtained from the department of insurance. The application form is
adopted by reference, and a copy may be obtained from the Department of
Insurance, 311 West Washington Street, Suite 300, Indianapolis, Indiana
46204.
(c) The completed
application form shall be accompanied by a description of the utilization
review plan that shall summarize the following information:
(1) Procedures established for appeal of an
adverse determination. These procedures must comply with section 6 of this
rule.
(2) Procedures established
for handling complaints by enrollees, patients, or health care providers. These
procedures must comply with section 9 of this rule.
(3) Policies and procedures that ensure that
all applicable state and federal laws to protect the confidentiality of medical
records are followed. These procedures must comply with section 8 of this
rule.
(d) The completed
application form shall contain the following information:
(1) A certification that the utilization
review agent will comply with the provisions of IC 27-8-17.
(2) The categories of persons employed to
perform utilization review. Personnel changes within the categories do not
constitute a material change in the application.
(3) A description of the hours of operation
within the state of Indiana and how the utilization review agent may be
contacted during weekends and holidays. This description must be in compliance
with section 7 of this rule.
(4)
Representative samples of materials provided by the utilization review agent or
applicant to inform its clients, enrollees, or providers of the requirements of
the utilization review plan.
(5) A
certification that the utilization review agent is in compliance with IC
27-8-17-19.
(e) The utilization review agent
shall report any material changes in the information in the application or
renewal form referred to in this section not later than the thirtieth day after
the date on which the change takes effect.
(f) The application process shall be as
follows:
(1) The department of insurance shall
have thirty (30) days after receipt of an application to determine whether the
application is complete. In the event that an application is found to be
incomplete, the department of insurance will give the applicant written notice
of the required information necessary to complete the application. If the
application is complete, the applicant will be advised that the application has
been received and accepted for review.
(2) The department of insurance shall have
sixty (60) days from the date the application is determined to be complete
under subdivision (1) to process the application and approve or disapprove it.
The department of insurance shall give the applicant written notice of any
deficiencies noted as a result of the review conducted under this
subdivision.
(3) The department of
insurance shall afford the applicant an opportunity for a meeting to discuss
any omissions or deficiencies noted.
(4) The applicant must correct the omissions
or deficiencies in the application within thirty (30) days of the date of the
latest notice of the department of insurance of such omissions or deficiencies.
If the applicant fails to do so, the application file will be closed as an
incomplete application. The application fee will not be refundable.
(5) The department of insurance shall
maintain an application file which shall contain the application, notices of
omissions or deficiencies, responses, and any written materials generated by
any person who was considered by the department of insurance in evaluating the
application.
(g) A
utilization review agent must apply for a certificate renewal every year, not
later than June 30. The initial renewal shall be completed by June 30, 1994. A
renewal form must be used for this purpose. The renewal fee must be submitted
with the renewal form. The renewal form can be obtained from the department of
insurance at the address listed in subsection (a). The completed renewal form
and the renewal fee must be submitted to the department of insurance at the
address listed in subsection (a). A utilization review agent may continue to
operate under its certificate after a completed renewal application form and
the renewal fee has been timely received by the department of insurance until
the renewal is finally denied or issued by the department of insurance. If a
completed renewal application and fee is not received prior to June 30, the
certificate will automatically be canceled, and the utilization review agent
must complete and submit a new application form with the new application fee
for another certificate of registration.
(h) If an application or renewal is initially
denied under this section, the applicant or registrant may appeal such denial
under the terms of the provisions of IC 4-21.5. A hearing of such appeal shall
be conducted within forty-five (45) days from the date the petition for hearing
is filed with the commissioner. A decision by the commissioner shall be
rendered within sixty (60) days from the date of the hearing.
(i) Applications that are filed on or before
February 28, 1993, will be processed on a first in, first out basis by the
department of insurance. The time lines set out for processing applications in
subsection (f) will not apply to these applications.
(j) Entities who were operating in Indiana as
utilization review agents on or after July 1, 1992, must file the application
described in subsections (a) through (d) by February 28, 1993. Those entities
may continue to operate as utilization review agents pending review of the
application unless they are advised in writing that the application has been
disapproved or closed as an incomplete application as described in subsection
(f). No entity may continue to operate after fifteen (15) days from the date of
the notice of the denial or closure of the file.
Notes
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