A. The director shall examine the affairs, transactions, accounts and records of each utilization review agent before issuing an initial certificate and as often as the director deems it necessary in order to determine if a utilization review agent is in compliance with this chapter. The department shall not make any determination of quality of care, appropriateness of utilization review recommendations or medical necessity relating to any plan of care or treatment.

Terms Used In Arizona Laws 20-2506

  • Contract: A legal written agreement that becomes binding when signed.
  • department: means the department of insurance and financial institutions. See Arizona Laws 20-101
  • Health care insurer: means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation, prepaid dental plan organization, medical service corporation, dental service corporation or optometric service corporation or a hospital, medical, dental and optometric service corporation. See Arizona Laws 20-2501
  • 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

B. All examination and examination related expenses shall be charged to the utilization review agent and shall be paid by the director out of the insurance examiners’ revolving fund in accordance with section 20-159.

C. The director may use independent contract examiners pursuant to sections 20-148 and 20-149 to perform the examinations under this section.

D. Any expenses of examinations not paid by the utilization review agent within thirty days of the billing of the examination expenses shall be paid by the health care insurer that used the services or that contracted with the utilization review agent. If more than one health care insurer used the services of or contracted with a utilization review agent each health care insurer shall pay an equal share of the uncollected expenses.

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