Current Status Introducing Body:Senate Bill Number:464 Primary Sponsor:Saleeby Committee Number:02 Type of Legislation:CR Subject:Utilization review firms, regulation of Residing Body:Senate Current Committee:Banking and Insurance Companion Bill Number:3225 Computer Document Number:464 Introduced Date:Jan 15, 1991 Last History Body:Senate Last History Date:Jan 15, 1991 Last History Type:Introduced, referred to Committee Scope of Legislation:Statewide All Sponsors:Saleeby Land McConnell Mullinax Pope Type of Legislation:Concurrent Resolution
Bill Body Date Action Description CMN
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464 Senate Jan 15, 1991 Introduced, referred to 02
Committee
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DIRECTING THE CHIEF INSURANCE COMMISSIONER TO PROMULGATE REGULATIONS FOR PROCEDURES TO BE FOLLOWED BY UTILIZATION REVIEW FIRMS INCLUDING ACCREDITATION, NOTIFICATION REQUIREMENTS, APPEALS PROCEDURES, ACCESSIBILITY OF REVIEW AGENCIES, PERSONNEL QUALIFICATIONS, INFORMATIONAL MATERIAL, CONFIDENTIALITY, AND UTILIZATION REQUIREMENTS.
Whereas, the South Carolina Joint Insurance Study Committee has conducted a study of utilization review firms doing business in South Carolina; and
Whereas, the study included consideration of the procedures to be followed by utilization review firms to insure the health and safety of the citizens of this State and the containment of health care costs in this State; and
Whereas, the promulgation of regulations by the Chief Insurance Commissioner is necessary to implement procedures to be followed by utilization review firms to achieve the health and safety of our citizens and health care cost containment. Now, therefore,
Be it resolved by the Senate, the House of Representatives concurring:
That the Chief Insurance Commissioner is directed to promulgate regulations, in accordance with the rule making authority vested in him, containing at least the following provisions:
(A) Each utilization review firm shall seek accreditation through the Utilization Accreditation Commission.
(B) Each utilization review firm shall establish procedures so that its operation is in accordance with the following requirements:
(1) Notification of Decisions Both Favorable and Adverse:
(a) Telephone notification of decisions within one business day must be communicated to the individual who requests a review telephonically (subscriber or provider).
(b) Written notification and decisions must be mailed to the insured or provider within five business days.
(2) Appeals Process:
(a) An initial appeal of a decision must be documented to have been reviewed by a licensed physician. In addition, a licensed physician consultant to the review agent must be available for direct appeals from providers within one business day of a request for appeal.
(b) The review agent must provide a structure for the conduct of formal grievance procedures. The formal grievance procedure must include a physician consultant and provide a review by a physician consultant in the medical specialty most appropriate to the case in question.
(c) The appeals process must contain specific time frames for the resolution of appealed cases:
(i) forty-eight hours for an informal appeal;
(ii) thirty days for a formal grievance process.
(3) Accessibility:
(a) The review agency must be accessible to insureds and providers in South Carolina for a minimum of forty hours a week during the hours of 9:00 a.m. to 5:00 p.m., South Carolina time.
(b) The review agency must provide toll-free telephone lines with sufficient accessibility to ensure a reasonable response to inquiry. A reasonable time frame for response would be an average telephone queue time not to exceed sixty seconds.
(4) Qualifications of Personnel:
At a minimum, the review agent must be a currently licensed nurse or physician. Additionally, the review agent must have the immediate availability of a licensed physician consultant for interface with providers in South Carolina.
(5) Booklets and other materials designed to inform patients regarding the requirements of the utilization plan and their rights and responsibility under that plan must include, at a minimum, correct telephone numbers and addresses of the review agent, and a description of the appeals process and the grievance process.
(6) Confidentiality of medical information must be assured. A confidentiality statement must be included in the informational materials described in (5) above. A description of medical record handling procedures also must be included in the application for a certificate.
(C) Application for a certificate filed by a review agent must include detailed specific references to the utilization criteria that form the basis of their utilization program. For example, InterQual criteria may be quoted as the source document for a utilization review program.