(A) The director or his designee may conduct periodic reviews of the operations of private review agents in this State to ensure that they continue to meet the specifications outlined in this chapter and any applicable regulations which may be promulgated by the department. The director or his designee may perform periodic telephone audits of private review agents authorized to conduct business in this State, to determine if the agents are reasonably accessible.

(B) Within ninety days upon receipt of a complaint from a licensed health care provider, the director or his designee may investigate the complaint, including holding hearings and taking testimony or other appropriate actions, and shall present a written response to the complainant and the private review agent named. This response must include the following:

Terms Used In South Carolina Code 38-70-40

  • Certificate: means a renewable certificate of registration granted by the director or his designee to a private review agent, authorizing the agent to perform utilization review activities in this State for two years. See South Carolina Code 38-70-10
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Department: means the Department of Insurance of South Carolina. See South Carolina Code 38-1-20
  • Director: means the person who is appointed by the Governor upon the advice and consent of the Senate and who is responsible for the operation and management of the department. See South Carolina Code 38-1-20
  • Director or his designee: means the director or his designee of the South Carolina Department of Insurance. See South Carolina Code 38-70-10
  • Private review agent: means a person performing utilization reviews who is either under contract with or acting on behalf of, but not employed by:

    (a) a South Carolina business entity;

    (b) the State of South Carolina; or

    (c) a hospital. See South Carolina Code 38-70-10
  • Testimony: Evidence presented orally by witnesses during trials or before grand juries.
  • Utilization review: means a system for reviewing the necessary, appropriate, and efficient allocation of health care resources and services given or proposed to be given to a patient or group of patients. See South Carolina Code 38-70-10

(1) a statement of the original complaint;

(2) a determination of findings of the director or his designee;

(3) corrective actions, if any, on the part of the private review agent which the director or his designee finds appropriate; and

(4) a time frame in which any corrective actions are to be completed.

(C) The director or his designee is authorized to take appropriate action against a private review agent who fails to meet the standards of this chapter or of any applicable regulations promulgated by the department, or who fails to respond in a timely fashion to corrective actions ordered by the director or his designee. The director or his designee may impose an administrative fine not to exceed one thousand dollars for each violation or may deny, suspend, or revoke the certificate of the private review agent.

(D) The director or his designee may also deny, suspend, or revoke a certificate if, upon review, the director or his designee finds that the private review agent does not:

(1) have a utilization review program that meets the requirements of subsection (C) of § 38-70-20;

(2) have available the services of sufficient numbers of registered nurses, medical records technicians, or similarly qualified persons supported and supervised by appropriate physicians to carry out its utilization review activities;

(3) meet any applicable regulations the department promulgates under this chapter relating to the qualifications of private review agents or the performance of utilization review;

(4) remain accessible to patients and providers.

(E) Before taking the actions authorized by this section to deny, suspend, or revoke the certificate of a private review agent, the director or his designee shall provide the private review agent with reasonable time to supply additional information demonstrating compliance with the requirements of this chapter and the opportunity to request a hearing. If a private review agent requests a hearing, the director or his designee shall send a hearing notice to the involved parties by certified mail, return receipt requested, at least thirty days before the hearing. The director or his designee shall hold the hearing in accordance with the provisions of Chapter 3 of this title, and the State Administrative Procedures Act. Any action or decision of the director or his designee pursuant to the administrative hearing may be appealed to the Administrative Law Court as provided by law by the private review agent.

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