Maine Revised Statutes Title 24-A Sec. 2772 – Minimum standards
Current as of: 2023 | Check for updates
|
Other versions
A utilization review program of the applicant must meet the following minimum standards. [PL 1989, c. 556, Pt. C, §2 (NEW).]
1. Notification of adverse decisions. Notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within a time period to be determined by the superintendent through rulemaking and must include the name of the utilization review agent who made the decision.
[PL 1993, c. 602, §5 (AMD).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 2772
- medical utilization review services: means a program or process by which a person, partnership or corporation, on behalf of an insurer, nonprofit service organization, 3rd-party administrator, health maintenance organization, preferred provider organization or employer that is a payor for or that arranges for payment of medical services, seeks to review the utilization, appropriateness or quality of medical services provided to a person whose medical services are paid for, partially or entirely, by that insurer, nonprofit service organization, 3rd-party administrator, health maintenance organization, preferred provider organization or employer. See Maine Revised Statutes Title 24-A Sec. 2773
2. Reconsideration of determinations. All licensees shall maintain a procedure by which insureds, patients or providers may seek reconsideration of determinations of the licensee.
[PL 1989, c. 556, Pt. C, §2 (NEW).]
3. Accessibility of representatives. A representative of the licensee must be accessible by telephone to insureds, patients or providers and the superintendent may adopt standards of accessibility by rule.
[RR 2015, c. 1, §27 (COR).]
3-A. Medical utilization review criteria. The licensee must have written medical utilization review criteria to be employed in the review process. The criteria must be available for review as a part of any review conducted pursuant to section 2774, subsection 1 and a copy of the criteria must be provided to the bureau upon request.
[PL 1995, c. 332, Pt. M, §7 (NEW).]
4. Information materials; confidentiality. A copy of the materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan and an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed must be filed with the bureau.
[PL 1989, c. 556, Pt. C, §2 (NEW).]
5. Penalty for noncompliance with utilization review programs. A medical utilization review program may not recommend or implement a penalty of more than $500 for failure to provide notification. This subsection does not limit the right of insurers to deny a claim when appropriate prospective or retroactive review concludes that services or treatment rendered were not medically necessary.
[PL 1995, c. 332, Pt. M, §8 (AMD).]
6. Prohibited activities. A medical utilization review entity shall ensure that an employee does not perform medical utilization review services involving a health care provider or facility in which that employee has a financial interest.
[RR 1993, c. 2, §15 (RNU).]
SECTION HISTORY
PL 1989, c. 556, §C2 (NEW). RR 1993, c. 2, §15 (COR). PL 1993, c. 602, §§5,6 (AMD). PL 1993, c. 645, §B4 (AMD). PL 1995, c. 332, §§M7,8 (AMD). RR 2015, c. 1, §27 (COR).