CHAPTER
Ins 2000 MEDICAL UTILIZATION REVIEW
ENTITIES
Statutory
Authority: RSA 400-A:15, I and RSA 420-E:7
PART
Ins 2001 LICENSURE OF MEDICAL
UTILIZATION REVIEW ENTITIES
Ins 2001.01 Purpose. The purpose of this chapter is to implement
RSA 420-E wherein the general court has provided for the licensure of medical
utilization review entities, oversight by the state of the procedures used by
such entities, and a requirement that such entities adhere to prescribed
minimum standards.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.02 Scope of Rule.
(a)
This chapter shall apply to any medical utilization review entity, as
defined under Ins 2001.03(b)(8), that performs medical utilization review
services with respect to beneficiaries whose insurance policies or certificates
or other evidence of health care expense coverage were delivered or issued for
delivery in New Hampshire.
(b)
This chapter shall not apply to any organization exempt under RSA
420-E:2, I or any person, partnership, or corporation if:
(1) Its medical utilization review activities are
performed solely for research purposes and are not used in any manner to
determine commensurability of pending claims or eligibility of covered persons
for benefits or continuation thereof; or
(2) Its medical utilization review activities are
performed solely pursuant to any program of the United States government and
are preempted under federal law, including but not limited to:
a. Title XVIII of the United States Social
Security Act;
b. The Civilian Health and Medical Program of
the United States (CHAMPUS), 10 U.S.C. 1072(4), Medicare; or
c. Title XIX of the United States Social
Security Act, Medicaid.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff
6-11-10; ss by #12545, eff 6-11-18
Ins 2001.03 Definitions.
(a)
For the purposes of this part, the definitions appearing under RSA
420-E:1 shall apply whenever any word or phrase defined under RSA 420-E:1 is
used in this part.
(b)
With respect to the following words or phrases used in this part, but
which are not defined under RSA 420-E:1, the following definitions shall apply:
(1) "Beneficiary" means any person or
his or her covered dependent who is receiving or is proposed to receive a
health care service covered under a health care benefit plan for which
utilization review is to be conducted;
(2) "Business days" means all days
other than weekends and legal holidays;
(3) "Confidential medical information"
means medical information that is not intended to be disclosed to third persons
other than those present to further the interest of the beneficiary in a
consultation, examination, or interview, or persons, including members of the
beneficiary's family, who are participating in the diagnosis and treatment of
the beneficiary under the direction of a physician, psychotherapist, or other
licensed health care provider;
(4) "Emergency" means a medical case
involving a critical, life-threatening condition requiring medical or surgical
care which, if not received immediately, would result in risk to
life;
(5) "Emergency notification
requirement" means the duty imposed upon a beneficiary by the
beneficiary's health care benefit plan to notify a medical utilization review
entity in the event of the beneficiary's receipt of emergency medical
treatment;
(6) "Exempt organization" means an
insurer, nonprofit service organization, health maintenance organization, preferred
provider organization, or an employee of an exempt organization;
(7) "Health care benefit plan" means a
contract or other agreement by which an insurer, a nonprofit service
organization, a health maintenance organization, a third party administrator,
or an employer arranges for or is the payor for health care services;
(8) "Medical utilization review entity"
means any person, partnership, or corporation that provides utilization review
services. The term includes “utilization review entity”;
(9)
"Medical utilization review
services" means those services that are performed in the conduct of
utilization review as defined under RSA 420-E:1, IV. The term includes
“utilization review services”;
(10) "National committee for quality
assurance (NCQA)" means the independent, nonprofit organization based in
Washington, D.C. whose primary purpose is to assess and report on the quality
of managed care plans, including health maintenance organizations;
(11) "Reasonable explanation" means that
sufficient information is provided to the beneficiary to enable the beneficiary
to effectively exercise the right of appeal;
(12) "Utilization review accreditation
commission (URAC)" means the voluntary, nonprofit organization based in
Washington, D.C. that provides a centralized review and accreditation process.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.04 Licensure Procedure.
(a)
No utilization review entity, other than an exempt organization, shall
perform utilization review services unless the entity has received a license
from the commissioner.
(b)
To obtain a medical utilization review license, the utilization review
entity shall make application to the commissioner by completing and submitting
an application form prescribed by the commissioner for this purpose under Ins
2001.07. This application shall be accompanied by the appropriate application
fee pursuant to Ins 2001.09.
(c)
Utilization review entities applying for a license shall provide
complete answers to all questions appearing on the application form. If the
space provided on the application form is not sufficient to provide the
applicant the space needed for a complete answer, the applicant shall provide
such additional information as is necessary to provide a complete answer on
additional sheets of paper which shall be attached to the application form.
(d)
Each medical utilization review entity that has an application pending
shall keep its application and any accompanying information or supporting
material current. Any amendments or other changes to any of the documents that
are part of or which accompany a pending application shall be filed within 30
days. Failure to comply with this requirement on the part of a medical
utilization review entity shall be considered a violation of this part.
(e)
Any applicant whose application is rejected shall be entitled to appeal
the denial in accordance with the provisions of RSA 541, RSA 541-A,
and Ins 200, and shall be so notified.
(f)
Licenses issued pursuant to this part shall expire at the end of
business on the March 31st following the date of issue. Such licenses shall be renewable pursuant to
Ins 2001.05.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9621-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.05 Procedures of Licensure Renewal.
(a)
In order to renew a medical utilization review license, the utilization
review entity shall make application for renewal to the commissioner by
completing and submitting an application form prescribed by the commissioner
for this purpose under Ins 2001.07. The renewal application shall be
accompanied by the appropriate fee pursuant to Ins 2001.09.
(b)
Renewal applications received shall be reviewed and approved or rejected by
the commissioner.
(c)
Any applicant whose renewal application is rejected shall be entitled to
appeal the denial in accordance with the provisions of RSA 541, RSA
541-A and Ins 200, and shall be so notified.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9621-A, eff
6-11-10; ss by #12545, eff 6-11-18
Ins 2001.06 Privileged Information. No information required to obtain a
utilization review license shall be withheld by an applicant on the grounds
that it is proprietary or otherwise confidential. Any information deemed confidential by the
applicant may be submitted under separate cover, accompanied by a statement of
the scope of the privilege claimed by the applicant and the basis for the claim
of privilege. The applicant shall have
the opportunity to request a hearing if the commissioner denies such a claim in
whole or in part.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.07 Forms Required.
(a)
The applicant for a medical utilization review license or for the
renewal of such license shall provide the following on Form INS-MURL-APP-1
Application for License as a Medical Utilization Review Facility:
(1) The exact name of the utilization review
entity for which application is made;
(2) The applicant's Federal I.D. number or Social
Security number;
(3) A statement as to whether the application is
for a new license or for renewal of a license;
(4) The applicant's current street address and
mailing address, if different;
(5) The name and address of the parent company if
the applicant is a subsidiary;
(6) The name and address of the medical director;
(7) Verification that the medical director is
licensed under RSA 329;
(8) A statement as to whether the applicant is a partnership, corporation, or
association, or other type of
organization such that:
a. If the applicant is a corporation, it shall
indicate the state of incorporation and list all states in which the
corporation does business; and
b. If the applicant represents a type of
organization other than a partnership, corporation, or association, it shall
specify its type of organization;
(9) A list of the principal proprietors,
partners, directors, officers, and administrators and any others
responsible for the operation, management, and control of the applicant;
(10)
A biographical sketch of all principal proprietors, partners, directors,
officers, and administrators listed which shall include,
at a minimum, the person's current business and home address, current
position(s), education, and previous experience;
(11) A statement showing the number of the
applicant's employees in New Hampshire and the estimated number of employees
nationally;
(12) If operations are conducted at more than one
location, whether in or outside of New Hampshire, a list of all locations, the
range of activities at each location, and the number of employees at each
location;
(13) A description of the types of medical
utilization review programs offered by the applicant, including but not limited
to:
a. Second opinion program;
b. Hospital preadmission review;
c. Preinpatient service eligibility
certification; and
d. Concurrent review to determine appropriate
length of a hospital stay;
(14) A description of the process by which the
applicant performs each of the medical utilization review services listed
pursuant to the requirement of Ins 2001.07(a)(13) and shall specify:
a. The steps followed by the applicant's
personnel in the performance of each type of review program; and
b. The categories of health care personnel that
perform medical utilization review for the applicant and whether those persons
are licensed in this or any other state;
(15) A description of the process used by the
applicant to address beneficiary and provider complaints, requests for
redeterminations, and appeals;
(16) A copy of all materials to be used by the
applicant to inform beneficiaries of the requirements of the utilization review
plans and the rights and responsibilities of the beneficiaries under the plan;
(17) A statement of whether the applicant's
utilization review program has been certified by either the Utilization
Review Accreditation Commissioner (URAC) or the National Committee for Quality
Assurance (NCQA);
(18) A statement of the telephone number or
numbers, including any toll-free numbers and fax numbers, at which
beneficiaries and providers may reach representatives of the applicant
including:
a. The number of lines maintained;
b. The hours and days of the week during which
representatives of the applicant may be contacted; and
c. Any hours or days of the week during which
calls are unanswered or are answered solely by recordings or answering services
which do not provide access to representatives during the call;
(19) A statement by the applicant describing the
procedures established for preserving the confidentiality of medical
information used in the utilization review process, including a signed
acknowledgment that the applicant shall sign stating that, "The
undersigned also acknowledges that all applicable state and federal laws to
protect the confidentiality of medical information will be followed."; and
(20) The signature of the applicant, or an officer
of the firm if the applicant is a firm, certifying the following statement:
"I have read the foregoing application and attachments and state that the
answers supplied therein are true and correct to the best of my knowledge and
belief. Further, by submitting this
application to the insurance department, the applicant acknowledges that it has
read and will comply with the performance standards set forth in RSA 420-E and
any applicable rules."
(b)
If the purpose of the application is to renew a license, the applicant
shall, in the course of providing the information required by Ins 2001.07(a)(4)
through (20), explain any changes from the most recent previous application on
file with the department.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-B, eff 6-11-10; ss by #12545, eff 6-11-18
Ins 2001.08 Change
in Name. Should any medical
utilization review entity that is licensed by the commissioner pursuant to this
part propose to undergo a change in name, the licensee shall, by letter to the
commissioner, request that its license or registration be transferred to the
licensee's or the organization's new name. The commissioner shall approve such a name
change, except in any case where the new name is either the same as or closely
resembles the name of any other licensee or registered exempt organization or
in any case where the new name is misleading or deceptive.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.09 Fees.
(a)
The application fee that shall accompany the application for a medical
utilization review license submitted pursuant to Ins 2001.04(b) shall be
$500.00.
(b)
The annual renewal fee that shall accompany an application for the
renewal of a medical utilization review license submitted pursuant to Ins
2001.05(a) shall be $100.
(c)
Fees payable pursuant to this section shall be payable to the State of
New Hampshire.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.10 Standards Relative to Time Periods for
Notification of Determinations.
(a)
No claim for benefits shall be denied or payment reduced on the basis of
an adverse medical utilization review determination except in accordance with
RSA 420-E:4.
(b)
All hospital preadmission review programs shall include specific
provisions concerning immediate hospitalization of a beneficiary for whom the
treating physician determines the admission to be an emergency, including
subsequent documentation of medical necessity.
(c)
Preadmission inpatient service eligibility programs shall include, but
not be limited to, a review of the medical necessity for admission to a skilled
nursing facility, intermediate care facility, or other long term care
facility as defined in the applicable health insurance contract, policy,
certificate, or other evidence of coverage.
(d)
When engaged in review to determine the appropriate length of an
inpatient hospital stay, no medical utilization review entity shall reduce or
recommend a reduction of benefits otherwise payable, based on a determination
that a hospital stay is medically unnecessary or inappropriate, unless
sufficient notice is given so that the beneficiary is allowed an expedited
review.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.11 Manner and Intent of Notification. The manner and intent of notifications of
claim benefit determinations shall be in accordance with the requirements of
RSA 420-E:4.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.12 Standards for Telephone Accessibility.
(a)
A medical utilization review entity shall maintain the number of
telephone lines reasonably necessary to service the volume of calls which it
may be expected to receive from beneficiaries and health care providers. The
medical utilization review entity shall ensure that an adequate number of
representatives respond to calls at least 7 days a week during the utilization
review entity’s normal working hours.
(b)
Medical utilization review entities may use computerized telephone
routing systems and may use systems for the receipt of information for which
replies are not required. Time periods
during which calls are answered solely by these systems or by answering
services shall not qualify toward meeting the requirements of Ins 2001.12(a).
(c)
A medical utilization review entity shall provide access to its review
staff by a toll free or collect phone line, at a minimum, from 9:00 a.m. to
4:00 p.m. of each standard business day, in the provider's local time zone.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.13 Reconsideration Procedures. A medical utilization review entity shall
establish an appeal process for addressing beneficiary and provider complaints
and requests for reconsiderations. No
license shall be issued pursuant to Ins 2001.04 unless and until a medical
utilization review entity has established an appeals process providing
assurances to beneficiaries and providers that their complaints and requests
for reconsiderations shall be fairly and objectively considered in accordance
with RSA 420-E:4.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.14 Confidentiality.
(a)
Each utilization review entity shall have written procedures for
assuring that patient-specific information obtained during the process of
utilization review shall be:
(1) Kept confidential in accordance with
applicable laws and rules;
(2) Used solely for the purposes of utilization
review, quality management, discharge planning, and case management;
(3) Shared only with the claims administrator and
other such persons who have authority to receive such information; and
(4) Limited to the information necessary for the
claims administrator to adjudicate the claim.
(b)
All data which provides sufficient information to allow identification
of an individual patient, enrollee, or claimant shall be considered
confidential medical information.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.15 Scope of Review. When conducting routine prospective,
concurrent, and retrospective utilization review, a medical utilization
review entity shall be entitled to collect and review only the information
necessary to certify the admission, procedure or treatment, length of stay, or
frequency and duration of services.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.16 Reviewers.
(a)
Medical utilization review entity personnel or exempt organization
personnel who are not licensed health care providers shall not communicate with
a beneficiary or provider except for the purpose of collecting and recording
demographic data. Demographic data shall
include information to identify the patient, enrollee, and attending physician
or other provider. Demographic data
shall not include any information related to the health or medical condition of
the patient.
(b)
All communications on the part of a medical utilization review entity or
exempt organization with either a beneficiary or provider, other than
communications carried out for the purpose of collecting and recording
demographic data, shall be conducted by personnel who are licensed health care
providers.
(c)
The medical director of the medical utilization review entity shall be a
New Hampshire licensed physician under RSA 329.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.17 Other Provisions.
(a)
A prerequisite for the licensing of a medical utilization review entity
shall be accreditation of the utilization review services performed by the
utilization review entity from the URAC or the NCQA.
(b)
A licensed medical utilization review entity shall allow any licensed
facility rendering service, physician, or responsible beneficiary
representative, including a family member, to assist in fulfilling any
certification or other managed care requirement.
(c)
Any written procedures maintained in order to comply with the standards
of the URAC or the NCQA by a
licensed medical utilization review entity shall be made available to the
insurance department upon the department's written request.
(d)
No claim for benefits shall be denied nor shall any payment be reduced
on the basis of an adverse medical utilization review determination unless the
beneficiary is given notice of the right to appeal. The notice shall contain an explanation of
the appeals process that shall be sufficient to enable the beneficiary to
effectively exercise the right of appeal.
(e)
A denial or reduction of benefits based on the failure of a provider to
supply the medical utilization review entity with complete information shall
describe in detail the information required but not received by the medical
utilization review entity.
Source. #5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.18 Compliance. Any violations of these rules by a medical
utilization review entity shall be subject to such denial, suspension, or
revocation of license or administrative fine not to exceed $1,000 per
violation, as may be applicable under RSA 420-E:8.
Source. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10;
ss by #12545, eff 6-11-18
Ins 2001.19 Waiver of Rules.
(a)
The commissioner, upon the commissioner’s own initiative or upon request
by an insurer, shall waive any requirement of this chapter if such waiver does
not contradict the objective or intent of the rule and:
(1) Applying the rule provision would cause
confusion or would be misleading to consumers;
(2) The rule provision is in whole or in part
inapplicable to the given circumstances;
(3) There are specific circumstances unique to
the situation such that strict compliance with the
rule would be onerous without promoting the objective or intent of the rule
provision; or
(4) Any other similar extenuating circumstances
exist such that application of an alternative standard or procedure better promotes
the objective or intent of the rule
provision.
(b)
No requirement prescribed by statute shall be waived unless expressly
authorized by law.
(c)
Any person or entity seeking a waiver shall make a request in writing.
(d)
A request for a waiver shall specify the basis for the waiver and
proposed alternative, if any.
Source. #12545, eff 6-11-18
APPENDIX A
|
Rule |
|
|
|
|
|
Ins
2001.01 |
RSA
400-A:15, I; RSA 420-E:7 |
|
Ins
2001.02 |
RSA
400-A:15, I; RSA 420-E:2; RSA 420-E:7 |
|
Ins
2001.03 |
RSA
400-A:15, I; RSA 420-E:1; RSA 420-E:7 |
|
Ins
2001.04 |
RSA
400-A:15, I; RSA 420-E:2; RSA 420-E:7, I, V & XI |
|
Ins
2001.05 |
RSA
400-A:15, I; RSA 420-E:7, I, VI, IX, & XII |
|
Ins
2001.06 |
RSA
400-A:15, I; RSA 420-E:3; RSA 420-E:7, V & VIII |
|
Ins
2001.07 |
RSA
400-A:15, I; RSA 420-E:7, I, VI, IX, & XII |
|
Ins
2001.08 |
RSA
400-A:15, I; RSA 420-E:7, V, VI, & XII |
|
Ins
2001.09 |
RSA
400-A:15, I; RSA 420-E:2; RSA 420-E:7, II |
|
Ins
2001.10 |
RSA
400-A:15, I; RSA 420-E:4, IV & V; RSA 420-E:7, III |
|
Ins
2001.11 |
RSA
400-A:15, I; RSA 420-E:4, IV & V; RSA 420-E:7, III |
|
Ins
2001.12 |
RSA
400-A:15, I; RSA 420-E:4, I; RSA 420-E:7, IV |
|
Ins
2001.13 |
RSA
400-A:15, I; RSA 420-E:4, V; RSA 420-E:7, XII |
|
Ins
2001.14 |
RSA
400-A:15, I; RSA 420-E:7, VIII |
|
Ins
2001.15 |
RSA
400-A:15, I; RSA 420-E:7, IX |
|
Ins
2001.16 |
RSA
400-A:15, I; RSA 420-E:2-a; RSA 420-E:4, II; RSA 420-E:7, X |
|
Ins
2001.17 |
RSA
400-A:15, I; RSA 420-E:3, II; RSA 420-E:4, III; RSA 420-E:7, XII |
|
Ins
2001.18 |
RSA
400-A:15; RSA 420-E:8 |
|
Ins
2001.19 |
RSA
400-A:15; RSA 541-A:22, IV |
APPENDIX
B
Form
INS-MURL-APP-1
Received _________________________
Approved ________________________
License No. ______________________
Issued ___________________________
STATE OF NEW HAMPSHIRE
INSURANCE DEPARTMENT
APPLICATION FOR LICENSE AS A
MEDICAL UTILIZATION REVIEW ENTITY
Application is hereby made on
behalf of the medical utilization review entity herein named for a license
authorizing it to transact business and to otherwise perform as a medical
utilization review entity in New Hampshire.
1.
The EXACT name of the medical utilization review entity is:________________________________
____________________________________________________________________________________
(If the name is not in English,
state it and give an exact literal translation.)
2.
The medical utilization review entity’s Federal ID number or Social
Security number is:
_____________________________________________________________________________________
_____________________________________________________________________________________
3.
This application is for (check one):
___________ A new license.
___________ Renewal of an existing license.
4.
The applicant’s current street address is: _________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5.
The applicant’s current mailing address is: _______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
6.
The name and address of the parent company, if the applicant is a
subsidiary: ____________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
7.
The name and address of the medical director: ____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
8.
Verification that the medical director is licensed under RSA 329: _____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
6.
The applicant is a (check one):
____________ Sole Proprietorship
____________ Partnership
____________ Corporation
____________ Other (please specify)
a. If
the applicant is a corporation, please specify the State of incorporation: ______________________________________________________________________________
b. List all states in which the corporation
does business:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7.
List the principal proprietors, partners, directors, officers and administrators. Also, include any others responsible for the
operation, management and control of the applicant. Attach a separate sheet of paper, if
necessary.
Name(s) Title(s)_______________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
8.
Attach separate sheets of paper giving biographical sketches of all
persons listed under question 7.
Include, at least, the person’s current business and home address, current
position(s), education and previous experience.
9.
The applicant has __________ employees in New Hampshire and
__________employees nationally.
10.
Locations. List all locations
from which operations are conducted whether in or outside of New Hampshire. Show the range of activities and the number
of employees at each location. Attach a
separate sheet if necessary.
Location (City and State) Activities No. of
Employees
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
11.
Describe the types of medical utilization review programs offered by the
applicant, including but not limited to:
a. Second
opinion program;
b. Hospital
preadmission review;
c. Pre-inpatient
service eligibility certification and
d. Concurrent
hospital review to determine appropriate length of stay.
IT IS REQUESTED THAT THE APPLICANT
PROVIDE THE INFORMATION REQUESTED BY ITEM 11 ON SEPARATE SHEETS OF PAPER
ATTACHED TO THE APPLICATION FORM.
12.
Describe the process by which the applicant proposes to perform each of
the utilization review services listed under (11) above. Specify (1) The steps
followed by the applicant’s personnel as they perform each type of review
program; and (2) the categories of health care personnel that perform medical
utilization review for the applicant, and whether those persons are licensed in
this or any other state.
IT IS REQUESTED THAT THE APPLICANT
PROVIDE THE INFORMATION REQUESTED BY ITEM 11 ON SEPARATE SHEETS OF PAPER
ATTACHED TO THE APPLICATION FORM.
13.
On separate sheets of paper attached to the application form, describe
the process that the applicant will use to address beneficiary and provider
complaints, requests for redeterminations and appeals.
14. The applicant is requested to enclose with the
application copies of all materials used by the applicant to inform
beneficiaries of the requirements of the utilization review plan and the rights
and responsibilities of beneficiaries under the plan.
15.
Has the applicant’s utilization review program been certified by the
Utilization Review Accreditation Commission (URAC) or the National Committee
for Quality Assurance (NCQA)? Please check one.
Yes______ No______
Note: The applicant is requested to attach a copy
of the accreditation certificate received from URAC or the NCQA.
16.
List the telephone number(s), including toll-free numbers and fax
numbers, at which beneficiaries and providers may reach representatives of the
applicant. For each number listed indicate the number of lines maintained and
the hours and days of the week during which the number is available.
Phone Number Number of Lines Days and Hours Available
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
16.a. Indicate the hours or days of the week during
which calls are unanswered or answered solely by the recordings or answering
services that do not provide access to representatives during the call.
17.
The applicant is requested to attach separate sheets of paper describing
the procedures established by the applicant for preserving the confidentiality
of medical information used in the utilization review process.
18.
I have read the foregoing application and attachments and state that the
answers supplied therein are true and correct to the best of my knowledge and
belief. The undersigned also acknowledges that all applicable state and federal
laws to protect the confidentiality of medical information will be followed.
Further, by submitting this application to the Insurance Department, the
applicant acknowledges that it has read and will comply with the performance
standards set forth in RSA 420-E and any applicable rules.
Signed on behalf of the applicant
by:
_____________________________________________________________________
Name (Typed) ________________________________________________________
Title: ________________________________________________________________
Date: ________________________________________________________________