TITLE XXXVII
INSURANCE

Chapter 420-E
LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES

Section 420-E:1

    420-E:1 Definitions. –
In this chapter:
I. "Commissioner" means the insurance commissioner.
I-a. "Claim involving urgent care" means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations:
(a) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
(b) In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
II. "Department" means the insurance department.
III. "Health care provider" means any person, corporation, facility, or institution either licensed by this state or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital or other health care facility, dentist, nurse, optometrist, podiatrist, physical therapist or psychologist, and any officer, employee or agent of such provider acting in the course and scope of his employment or agency related to or supportive of health care services.
III-a. "Pre-service claim" means any claim for a benefit under a health plan with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.
IV. "Utilization review" means a system for reviewing the appropriate and efficient allocation of hospital, medical or other health care services given to a patient or group of patients as to necessity, for the purpose of recommending or determining whether such services should be covered or provided by an insurer, nonprofit service organization, health maintenance organization, third-party administrator or employer. The terms include those programs or processes whether they apply prospectively or retrospectively to medical services. Utilization review services include, but are not limited to, the following: second opinion programs; prehospital admission certification; preinpatient service eligibility certification; and concurrent hospital review to determine appropriate length of stay. Utilization review shall not include claims review or decisions.

Source. 1992, 142:2. 1996, 188:12. 2001, 207:4, 5, eff. Jan. 1, 2002.

Section 420-E:2

    420-E:2 Licensure or Registration Required. –
I. Any person, partnership or corporation, other than an insurer, nonprofit service organization, health maintenance organization, or an employee of those exempt organizations, that performs medical utilization review services on behalf of commercial insurers, nonprofit service organizations, health maintenance organizations, third-party administrators or employers, shall apply for a license to be issued by the department and shall pay an application fee and an annual license fee. No person, partnership or corporation, other than an insurer, nonprofit service organization, health maintenance organization, or the employees of exempt organizations shall perform utilization review services or medical utilization review services unless the person, partnership, or corporation has received a license in accordance with this chapter.
II. [Repealed.]

Source. 1992, 142:2. 1993, 249:1. 1996, 188:13. 1997, 345:8, III. 1999, 249:4, eff. Sept. 7, 1999.

Section 420-E:2-a

    420-E:2-a Medical Director. – Every medical utilization review entity licensed by the department under this chapter shall employ a medical director licensed under RSA 329 or, in the case of a dental utilization review entity, a dentist licensed under RSA 317-A.

Source. 2000, 18:3. 2004, 187:5, eff. July 31, 2004.

Section 420-E:3

    420-E:3 Information Required. –
I. Each person, partnership or corporation licensed under this chapter shall, at the time of initial licensure and on or before April 1 of each succeeding year, provide the department with the following information:
(a) The process used by the entity to carry out its utilization review services, including the categories of health care personnel that perform utilization review activities and whether or not such individuals are licensed in this state.
(b) The process used by the entity for addressing beneficiary or provider complaints.
(c) The types of utilization review programs offered by the entity, including, but not limited to:
(1) Second opinion programs.
(2) Prehospital admission certification.
(3) Preinpatient service eligibility determination.
(4) Concurrent hospital review to determine appropriate length of stay.
(d) The process used by the entity to preserve beneficiary confidentiality of medical information.
II. Each person, partnership, or corporation licensed under this chapter shall adopt as the minimal acceptable standards for licensure either the Utilization Review Accreditation Commission (URAC) standards, the National Committee for Quality Assurance (NCQA) standards, or other similar standards acceptable to the commissioner, unless rules establishing stricter standards are adopted pursuant to the commissioner's authority under RSA 420-E:7, XII.

Source. 1992, 142:2. 1993, 249:2. 1999, 249:5, eff. Sept. 7, 1999.

Section 420-E:4

    420-E:4 Minimum Standards; Licensure of Medical Utilization Review Entities. –
All licensees shall establish and maintain a utilization review procedure by which a claimant or claimant's representative may seek a claim benefit determination. The procedure shall meet the following minimum standards:
I. The licensee shall maintain a toll-free telephone number to ensure that a representative of the licensee shall be accessible by telephone to insureds, patients, and providers 7 days a week during normal working hours.
II. Claim benefit determinations shall be made by a licensed or certified health care provider.
III. Clinical review criteria considered or utilized in making claim benefit determinations shall be:
(a) Developed with input from appropriate actively practicing practitioners in the carrier or other licensed entity's service area;
(b) Updated at least biennially and as new treatments, applications, and technologies emerge;
(c) Developed in accordance with the standards of national accreditation entities:
(d) Based on current, nationally accepted standards of medical practice; and
(e) If practicable, evidence-based.
IV. Notification of claim benefit determinations shall be made within the following time periods:
(a) The determination of a claim involving urgent care shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 72 hours after receipt of the claim, unless the claimant or claimant's representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable. In the case of such failure, the licensee shall notify the claimant or claimant's representative within 24 hours of receipt of the claim and shall advise the claimant or claimant's representative of the specific information necessary to determine the claim. The claimant or claimant's representative shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. Thereafter, notification of the benefit determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.
(b) The determination of a claim involving urgent care and relating to the extension of an ongoing course of treatment and involving a question of medical necessity shall be made within 24 hours of receipt of the claim; provided, that the claim is made at least 24 hours prior to the expiration of the prescribed period of time or course of treatment.
(c) The determination of all other claims for preservice benefits shall be made within a reasonable time period appropriate to the medical circumstances, but in no event more than 15 days after receipt of the claim. This period may be extended one time by the licensee for up to 15 days; provided, that the licensee both determines that such an extension is necessary due to matters beyond the control of the licensee and notifies the claimant or claimant's representative, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which the licensee expects to render a decision. If such an extension is necessary due to a failure of the claimant or claimant's representative to provide sufficient information to determine whether, or to what extent, benefits are covered as payable, the notice of extension shall specifically describe the required additional information needed, and the claimant or claimant's representative shall be given at least 45 days from receipt of the notice within which to provide the specified information. Notification of the benefit determination following a request for additional information shall be made as soon as possible, but in no case later than 15 days after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.
(d) The determination of a post service claim shall be made within 30 days of the date of filing. In the event the claimant fails to provide sufficient information to determine the claim, the carrier shall notify the claimant within 15 days as to what additional information is required to process the claim and the claimant shall be given at least 45 days to provide the required information. The 30-day period for claim determination shall be tolled until such time as the claimant submits the required information.
V. The manner and content of notification of claim benefit determinations shall be as follows:
(a) The licensee shall notify the claimant or claimant's representative in writing or electronically of the claim determination.
(b) If the claim benefit determination is a claim denial, the notice shall include:
(1) The specific reason or reasons for the determination and shall refer to the specific provision of the policy or plan on which the determination is based.
(2) A statement of the claimant's right or the right of the claimant's representative to access the internal grievance process and the process for obtaining external review.
(3) If the claim denial is based upon a determination that the claim is experimental or investigational or not medically necessary or appropriate:
(A) The name and credentials of the carrier or other licensed entity, the medical director, including board status and the state or states where the person is currently licensed. If the person making the claim denial is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person; and
(B) An explanation of the clinical rationale for the determination. This explanation shall recite the terms of the plan or the policy or of any clinical review criteria or any internal rule, guideline, protocol, or other similar provision that was relied upon in making the claim denial and how these provisions apply to the claimant's specific medical circumstances;
(4) If an internal rule, guideline, protocol, or other similar provision was relied upon in making the benefit determination, a statement that such rule, guideline, protocol, or other similar provision was relied upon in making the claim denial;
(5) If clinical review criteria were relied upon in making the benefit determination, a statement that such clinical review criteria were relied upon in making the claim denial. The recitation of terms of the clinical review criteria required under RSA 420-E:4, V(b)(3)(B) shall be accompanied by the following notice: "The clinical review criteria provided to you are used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract;"
(6) In the case of a denial of a benefit concerning a claim involving urgent care or in the case of a denial of a claim related to continuation of an ongoing course of treatment for a person who has received emergency services, but who has not been discharged from a facility, a description of the expedited review applicable to such a claim shall be included in the determination. For all other claim benefit determinations, a description of the grievance process shall be specifically described in the determination.
VI. A licensee shall file with the department a copy of the materials designed to inform 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.
VII. In any request for a benefit determination, the claimant may authorize a representative to pursue the claim or benefit determination by submitting a written statement to the licensee that acknowledges the representation.
VIII. No fees or costs shall be assessed against a claimant related to a request for claim benefit determination.

Source. 1992, 142:2. 1993, 249:3. 1996, 270:1. 2000, 18:16. 2001, 207:6. 2003, 276:8-10. 2006, 304:4, eff. Aug. 18, 2006.

Section 420-E:4-a

    420-E:4-a Uniform Prior Authorization Forms and Electronic Standard for Prescription Drug Benefits. –
I. Beginning July 1, 2017, all health insurers, health maintenance organizations, health services corporations, medical services corporations, and preferred provider programs may, when requiring prior authorization for a prescription drug, use and accept the prior authorization paper forms or electronic standard described in this section.
II. Beginning December 31, 2017, all health insurers, health maintenance organizations, health services corporations, medical services corporations, and preferred provider programs shall, when requiring prior authorization for a prescription drug, use and accept only the prior authorization paper forms or electronic standard described in this section.
III. On or before March 1, 2017, the commissioner shall adopt rules, pursuant to RSA 541-A, specifying the contents and format of the uniform prior authorization paper forms and the electronic prior authorization standard, consistent with the requirements of this section. In developing the paper forms and the electronic standard, the commissioner shall seek input from interested stakeholders, including but not limited to prescribers, pharmacists, carriers, and prescription benefits managers, and shall support adoption of nationally recognized standards for electronic prior authorization of prescription drugs, including those provided by the National Council for Prescription Drug Programs or an equivalent organization as available.
IV. The prior authorization paper forms adopted under this section shall not exceed 2 pages in length.
V. Nothing in this section shall require a carrier or pharmacy benefits manager to use electronic prior authorization. A carrier or pharmacy benefits manager shall not require use of electronic prior authorization when:
(a) A pharmacist or prescriber lacks broadband Internet access;
(b) A pharmacist or prescriber has low patient volume;
(c) A pharmacist or prescriber has opted-out for a certain medical condition or for a patient request;
(d) A pharmacist or prescriber lacks an electronic medical record system;
(e) The electronic prior authorization interface does not provide for the pre-population of prescriber and patient information; or
(f) The electronic prior authorization interface requires an additional cost to the prescriber.
VI. Nothing in this section shall prohibit the use of prior authorization for prescription drug benefits.
VII. This section shall apply to RSA 420-J and shall not apply to the Medicaid managed care program under RSA 126-A:5, XIX.

Source. 2016, 228:3, eff. June 9, 2016.

Section 420-E:5

    420-E:5 Listing. – The commissioner shall compile and maintain a current listing of persons, partnerships or corporations licensed pursuant to this chapter. The list shall be available to the public.

Source. 1992, 142:2, eff. July 5, 1992.

Section 420-E:6

    420-E:6 Periodic Reviews. – The commissioner or designee may conduct periodic reviews of the operations of the entities licensed under this chapter to ensure that they continue to meet the minimum standards set in RSA 420-E:4 and any applicable rules adopted by the commissioner. The commissioner may perform periodic telephone audits of licensees to determine if representatives of the licensee are reasonably accessible, as required in RSA 420-E:4, I.

Source. 1992, 142:2. 2001, 207:7, eff. Jan. 1, 2002.

Section 420-E:7

    420-E:7 Rulemaking. –
The commissioner shall adopt rules, under RSA 541-A and after public hearing, relative to:
I. Procedures for application for license under RSA 420-E:2.
II. Initial application fees and annual license fees.
III. The time period for notification of determination as required under RSA 420-E:4, IV.
IV. Standards for telephone accessibility as required under RSA 420-E:4, I.
V. Manner for filing and other information for minimum standards as required under RSA 420-E:4.
VI. Manner and content of all forms required under this chapter.
VII. What shall constitute cause to take actions under RSA 420-E:6 and RSA 420-E:8.
VIII. Confidentiality of records and access to records of the provider and reviewer, as required under RSA 420-E:4.
IX. The scope of the review and the information which the reviewer is entitled to review and have access to from the provider.
X. Qualification of the reviewer, as required under RSA 420-E:4, II.
XI. Procedures for registration.
XII. Additional standards for licensure of medical utilization review entities under RSA 420-E:3, II.

Source. 1992, 142:2. 1993, 249:4. 2001, 207:8, 9. 2012, 171:24, eff. Aug. 10, 2012.

Section 420-E:8

    420-E:8 Enforcement; Administrative Fine; Hearings. –
I. The commissioner may take appropriate action against a licensee which fails to meet the standards under this chapter or any rules adopted by the commissioner, or who fails to respond in a timely manner to corrective actions ordered by the commissioner. The commissioner may impose an administrative fine not to exceed $1,000 for each violation or may deny, suspend or revoke the license.
II. Before taking the actions authorized by this section to deny, suspend or revoke the license, the commissioner shall provide the licensee with reasonable time to supply additional information demonstrating compliance with the requirements of this chapter and the opportunity to request a hearing under RSA 541-A. Rehearings and appeals shall be conducted in accordance with RSA 541.

Source. 1992, 142:2, eff. July 5, 1992.

Section 420-E:9

    420-E:9 Rulings on Appropriateness of Medical Judgments Not Authorized. – Nothing in this chapter requires or authorizes the commissioner to rule on the appropriateness of medical decisions or judgments rendered by review entities and their agents.

Source. 1992, 142:2, eff. July 5, 1992.