(a) Whenever the department has reason to believe that a utilization review agent subject to this chapter has been or is engaged in conduct that violates this chapter, the department shall notify the utilization review agent of the alleged violation. The agent shall respond to the notice not later than 30 days after the notice is made.

Terms Used In Alabama Code 27-3A-6. Violations of chapter by utilization review agent

  • department: The Alabama Department of Public Health. See Alabama Code 27-3A-3
  • following: means next after. See Alabama Code 1-1-1
  • utilization review: A system for prospective and concurrent review of the necessity and appropriateness in the allocation of health care resources and services given or proposed to be given to an individual within this state. See Alabama Code 27-3A-3
  • utilization review agent: Any person or entity, including the State of Alabama, performing a utilization review, except the following:

    a. See Alabama Code 27-3A-3

  • writing: includes typewriting and printing on paper. See Alabama Code 1-1-1

(b) If the department finds that the utilization review agent has violated this chapter, or that the alleged violation has not been corrected, the department may conduct a contested case hearing on the alleged violation in accordance with the Administrative Procedure Act.

(c) If, after the hearing, the department determines that the utilization review agent has engaged in a violation, the department shall reduce the findings to writing and shall issue and cause to be served upon the agent a copy of the findings and an order requiring the agent to cease and desist from engaging in the violation.

(d) The department may also exercise either or both of the following disciplinary powers:

(1) Impose an administrative fine of not more than five thousand dollars ($5,000) for a violation that occurred with such frequency as to indicate a general business pattern or practice.

(2) Suspend or revoke the certification of a utilization review agent if the agent knew the act was in violation of this chapter and repeated the act with such frequency as to indicate a general business pattern or practice.

(Acts 1994, 1st Ex. Sess., No. 94-786, p. 80, §6.)