2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9428 - Operational requirements

(a) A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health insurance organization or issuer may develop its own clinical review criteria or it may obtain or use license clinical review criteria from qualified vendors. A health insurance organization or issuer shall make its clinical review criteria available upon request to the Commissioner and other authorized government agencies.
(b) Qualified healthcare professionals shall administer the utilization review program and oversee utilization review decisions. One (1) or more clinical peers shall evaluate the clinical appropriateness of adverse determinations.
(c)
(1) A health insurance organization or issuer shall conduct utilization reviews and issue benefit determinations in a timely manner pursuant to the requirements of §§ 9429 and 9430 of this title.
(2)
(A) Whenever a health insurance organization or issuer fails to adhere to the requirements of § 9429 or 9430 of this title, the covered person or enrollee shall be deemed to have exhausted the provisions of this chapter and may take action under paragraph (B) of this clause, whether the health insurance organization or issuer alleges to have substantially met the requirements of § 9429 or 9430 of this title, or if it alleges a de minimus violation.
(B)
(i) In accordance with the provisions of paragraph (A) of this clause, a covered person or enrollee may file a request for external review in accordance with the procedures outlined §§ 9501–9517 of this title.
(ii) In addition to the external review process provided in subparagraph (i) above, a covered person or enrollee shall be entitled to pursue any available remedies under Commonwealth or federal law on the basis that the health insurance organization or issuer failed to provide a reasonable internal grievances process that would yield a decision on the merits of the claim.
(d) A health insurance organization or issuer shall have a process to ensure that utilization reviewers apply clinical review criteria in conducting utilization review consistently.
(e) A health insurance organization or issuer shall routinely assess the effectiveness and efficiency of its utilization review program.
(f) A health insurance organization or issuer's data systems shall be sufficient to support utilization review program activities and to generate management reports to enable the health insurance organization or issuer to monitor and manage healthcare services effectively.
(g) If a health insurance organization or issuer delegates any utilization review activities to a utilization review organization, the health insurance organization or issuer shall maintain adequate oversight, which shall include:
(1) A written description of the utilization review organization's activities and responsibilities, including reporting requirements;
(2) evidence of formal approval of the utilization review organization program by the health insurance organization or issuer, and
(3) a process by which the health insurance organization or issuer evaluates the performance of the utilization review organization.
(h) The health insurance organization or issuer shall coordinate the utilization review program with other medical management activity conducted by the issuer, such as quality assurance, credentialing, provider contracting, data reporting, grievance procedures, processes for assessing covered person or enrollee's satisfaction and risk management.
(i) A health insurance organization or issuer shall provide covered persons or enrollees and participating providers with adequate mechanisms to clear up any doubts or questions related to the review and benefit determination program.
(j) When conducting utilization review, the health insurance organization or issuer shall collect only the information necessary, including pertinent clinical information, to make the utilization review.
(k)
(1) The health insurance organization or issuer shall ensure that the utilization review process is conducted in a manner to ensure the independence and impartiality of the individuals involved in making the utilization review or benefit determination.
(2) In ensuring the independence and impartially of individuals involved in making the utilization review or benefit determination, the health insurance organization or issuer shall not make decisions regarding hiring, compensation, termination, promotion or other similar matters with respect to such individuals based upon the likelihood that the individual will support the denial of benefits.
History —Aug. 29, 2011, No. 194, added as § 24.080 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.