Section 760IAC1-46-4. General standards of utilization review

   The utilization review plan, including appeal requirements, shall be conducted in accordance with standards or guidelines developed with input from appropriate health care providers and approved by a physician. The utilization review plan shall include the following components:

(1) Written procedures for:

(A) Notification of the utilization review agent's determinations provided to the enrollee, a person acting on behalf of the enrollee, or the enrollee's provider of record as addressed in section 5 of this rule.

(B) Appeal of an adverse determination and a copy of any forms used during the appeal process, as required by section 6 of this rule.

(C) Receiving or redirecting toll free telephone calls during normal business hours and after hour calls, either in person or by recording, and assurance that a toll free number will be maintained forty (40) hours per week during normal business hours as addressed in section 7 of this rule.

(D) Reviewing, including the following:

(i) Any form used during the review process.

(ii) Time frames that shall be met during the review.

(E) Handling of written complaints by enrollees, patients, or health care providers, as addressed in section 9(a) of this rule.

(F) Determining if health care providers utilized by the utilization review agent are licensed.

(G) Orientation and training of personnel who perform utilization review.

(H) Assuring that patient-specific information obtained during the process of utilization review, as addressed in section 8 of this rule, will be:

(i) kept confidential in accordance with applicable federal and state laws;

(ii) used for purposes of utilization review, quality assurance, discharge planning, and catastrophic case management;

(iii) shared with only those agencies (such as the claims administrator) that have authority to receive such information; and

(iv) summary data shall not be considered confidential if it does not provide sufficient information to allow for identification of individual patients.

(2) Each utilization review agent shall utilize written screening criteria and review procedures that are established and periodically evaluated and updated with appropriate involvement from health care providers. Such written screening criteria and review procedures shall be available for review and inspection by the commissioner or a designated department of insurance representative and copying, as necessary, for the commissioner to carry out his or her lawful duties under the Insurance Code, provided; however, that any information obtained or acquired under the authority of this rule and IC 27-8-17 is confidential and privileged and not subject to the open records law or subpoena except to the extent necessary for the commissioner to enforce this rule and IC 27-8-17.

(3) Utilization review decisions shall be made in accordance with standards or guidelines that are developed with input from appropriate health care providers and approved by a physician.

(Department of Insurance; 760 IAC 1-46-4; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1393; errata filed Feb 10, 1993, 4:00 p.m.: 16 IR 1514; readopted filed Sep 14, 2001, 12:22 p.m.: 25 IR 531; readopted filed Nov 27, 2007, 4:01 p.m.: 20071226-IR-760070717RFA; readopted filed Nov 26, 2013, 3:43 p.m.: 20131225-IR-760130479RFA)