A. A utilization review agent shall not conduct utilization review in this state unless the utilization review agent meets or is exempt from this article.

Terms Used In Arizona Laws 20-2502

  • Denial: means a direct or indirect determination regarding all or part of a request for any service or a direct determination regarding a claim that may trigger a request for review or reconsideration. See Arizona Laws 20-2501
  • department: means the department of insurance and financial institutions. See Arizona Laws 20-101
  • Person: includes a corporation, company, partnership, firm, association or society, as well as a natural person. See Arizona Laws 1-215
  • Process: means a citation, writ or summons issued in the course of judicial proceedings. See Arizona Laws 1-215
  • United States: includes the District of Columbia and the territories. See Arizona Laws 1-215
  • Utilization review: means a system for reviewing the appropriate and efficient allocation of inpatient hospital resources, inpatient medical services and outpatient surgery services that are being given or are proposed to be given to a patient, and of any medical, surgical and health care services or claims for services that may be covered by a health care insurer depending on determinable contingencies, including without limitation outpatient services, in-office consultations with medical specialists, specialized diagnostic testing, mental health services, emergency care and inpatient and outpatient hospital services. See Arizona Laws 20-2501
  • Utilization review agent: means a person or entity that performs utilization review. See Arizona Laws 20-2501
  • Utilization review plan: means a summary description of the utilization review guidelines, protocols, procedures and written standards and criteria of a utilization review agent. See Arizona Laws 20-2501

B. A person is exempt from sections 20-2504, 20-2505, 20-2506, 20-2507 and 20-2508 and section 20-2509, subsection A if the person:

1. Is accredited by the utilization review accreditation commission, the national committee for quality assurance or any other nationally recognized accreditation process recognized by the director.

2. Conducts internal utilization review for hospitals, home health agencies, clinics, private offices or other health facilities or entities if the review does not result in the approval or denial of payment for hospital or medical services.

3. Conducts utilization review activities exclusively for work related injuries and illnesses covered under the workers’ compensation laws in title 23.

4. Conducts utilization review activities exclusively for a self-funded or self-insured employee benefit plan if the regulation of that plan is preempted by section 514(b) of the employee retirement income security act of 1974 (29 United States Code § 1144(b)).

C. A utilization review agent shall conduct utilization review in accordance with the agent’s utilization review plan that is on file with the department pursuant to section 20-2505 and in accordance with section 20-2532.

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