Arkansas Administrative Code › Agency 054 - Arkansas Insurance Department › Rule 054.00.11-002 - Rule 76 - Arkansas External Review Regulation

Current through Register Vol. 49, No. 6, June, 2024
Section 1.
Authority
This regulation is promulgated pursuant to Ark. Code Ann.
			 §§
								23-61-108,
			 23-66-205,
			 23-66-207,
			 23-99-414,
			 25-15-203
			 & 204, and other applicable laws or rules.
Section 2.
Purpose and Intent
The purpose of this Rule is to provide uniform standards for the
			 establishment and maintenance of external review procedures to assure that
			 covered persons have the opportunity for an independent review of an adverse
			 determination or final adverse determination, as defined in this Rule.
Section 3.
Definitions
For purposes of this Rule:
A. "Adverse determination" means a
		  determination by a health carrier or its designee utilization review
		  organization that an admission, availability of care, continued stay or other
		  health care service that is a covered benefit has been reviewed and, based upon
		  the information provided, does not meet the health carrier's requirements for
		  medical necessity (or substantially equivalent term), appropriateness, health
		  care setting, level of care or effectiveness, and the requested service or
		  payment for the service is therefore denied, reduced or terminated.
B. "Ambulatory review" means utilization
		  review of health care services performed or provided in an outpatient
		  setting.
C. "Authorized
		  representative" means:
(1) A person to whom a
		  covered person has given express written consent to represent the covered
		  person in an external review;
(2) A
		  person authorized by law to provide substituted consent for a covered person;
		  or
(3) A family member of the
		  covered person or the covered person's treating health care professional only
		  when the covered person is unable to provide consent.
D. "Best evidence" means evidence based on:
(1) Randomized clinical trials;
(2) If randomized clinical trials are not
		  available, cohort studies or case-control studies;
(3) If paragraphs (1) and (2) are not
		  available, case-series; or
(4) If
		  paragraphs (1), (2) and (3) are not available, expert opinion.
E. "Case-control study" means a
		  retrospective evaluation of two (2) groups of patients with different outcomes
		  to determine which specific interventions the patients received.
F. "Case management" means a coordinated set
		  of activities conducted for individual patient management of serious,
		  complicated, protracted or other health conditions.
G. "Case-series" means an evaluation of a
		  series of patients with a particular outcome, without the use of a control
		  group.
H. "Certification" means a
		  determination by a health carrier or its designee utilization review
		  organization that an admission, availability of care, continued stay or other
		  health care service has been reviewed and, based on the information provided,
		  satisfies the health carrier's requirements for medical necessity (or
		  substantially equivalent term), appropriateness, health care setting, level of
		  care and effectiveness.
I.
		  "Clinical review criteria" means the written screening procedures,
decision abstracts, clinical protocols and practice guidelines
			 used by a health carrier to determine the necessity and appropriateness of
			 health care services.
J.
		  "Cohort study" means a prospective evaluation of two (2) groups of patients
		  with only one group of patients receiving a specific intervention(s).
K. "Commissioner" means the Arkansas
		  Insurance Commissioner.
L.
		  "Concurrent review" means utilization review conducted during a patient's
		  hospital stay or course of treatment.
M. "Covered benefits" or "benefits" means
		  those health care services to which a covered person is entitled under the
		  terms of a health benefit plan.
N.
		  "Covered person" means a policyholder, subscriber, enrollee or other individual
		  participating in a health benefit plan.
O. "Discharge planning" means the formal
		  process for determining, prior to discharge from a facility, the coordination
		  and management of the care that a patient receives following discharge from a
		  facility.
P. "Disclose" means to
		  release, transfer or otherwise divulge protected health information to any
		  person other than the individual who is the subject of the protected health
		  information.
Q. "Emergency medical
		  condition" means the sudden and, at the time, unexpected onset of a health
		  condition or illness that requires immediate medical attention, where failure
		  to provide medical attention would result in a serious impairment to bodily
		  functions, serious dysfunction of a bodily organ or part, or would place the
		  person's health in serious jeopardy.
R. "Emergency services" means health care
		  items and services furnished or required to evaluate and treat an emergency
		  medical condition.
S.
		  "Evidence-based standard" means the conscientious, explicit and judicious use
		  of the current best evidence based on the overall systematic review of the
		  research in making decisions about the care of individual patients.
T. "Expert opinion" means a belief or an
		  interpretation by specialists with experience in a specific area about the
		  scientific evidence pertaining to a particular service, intervention or
		  therapy.
U. "Facility" means an
		  institution providing health care services or a health care setting, including
		  but not limited to, hospitals and other licensed inpatient centers, ambulatory
		  surgical or treatment centers, skilled nursing centers, residential treatment
		  centers, diagnostic, laboratory and imaging centers, and rehabilitation and
		  other therapeutic health settings.
V. "Final adverse determination" means an
		  adverse determination involving a covered benefit that has been upheld by a
		  health carrier, or its designee utilization review organization, at the
		  completion of the health carrier's internal appeal process procedures. If the
		  health carrier does not have, nor is it required to have, an internal appeal
		  procedure or utilization review procedure, an adverse determination shall be
		  considered a final adverse determination.
W. "Health benefit plan" means a policy,
		  contract, certificate or agreement offered or issued by a health carrier to
		  provide, deliver, arrange for, pay for or reimburse any of the costs of health
		  care services.
X. "Health care
		  professional" means a physician or other health care practitioner licensed,
		  accredited or certified to perform specified health care services consistent
		  with state law
Y. "Health care
		  provider" or "provider" means a health care professional or a
		  facility.
Z. "Health care services"
		  means services for the diagnosis, prevention, treatment, cure or relief of a
		  health condition, illness, injury or disease.
AA. "Health carrier" means an entity subject
		  to the insurance laws and regulations of Arkansas, or subject to the
		  jurisdiction of the Commissioner, that contracts or offers to contract to
		  provide, deliver, arrange for, pay for or reimburse any of the costs of health
		  care services, including an accident and health insurance company, a health
		  maintenance organization, a nonprofit hospital and medical service corporation,
		  or any other entity providing a plan of health insurance, health benefits or
		  health care services.
BB. "Health
		  information" means information or data, whether oral or recorded in any form or
		  medium, and personal facts or information about events or relationships that
		  relates to:
(1) The past, present or future
		  physical, mental, or behavioral health or condition of an individual or a
		  member of the individual's family;
(2) The provision of health care services to
		  an individual; or
(3) Payment for
		  the provision of health care services to an individual.
CC. "Independent review organization" means
		  an entity that conducts independent external reviews of adverse determinations
		  and final adverse determinations.
DD. "Medical or scientific evidence" means
		  evidence found in the following sources:
(1)
		  Peer-reviewed scientific studies published in or accepted for publication by
		  medical journals that meet nationally recognized requirements for scientific
		  manuscripts and that submit most of their published articles for review by
		  experts who are not part of the editorial staff;
(2) Peer-reviewed medical literature,
		  including literature relating to therapies reviewed and approved by a qualified
		  institutional review board, biomedical compendia and other medical literature
		  that meet the criteria of the National Institutes of Health's Library of
		  Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for
		  indexing in Excerpta Medicus (EMBASE);
(3) Medical journals recognized by the
		  Secretary of Health and Human Services under Section 1861(t)(2) of the federal
		  Social Security Act;
(4) The
		  following standard reference compendia:
(a)
		  The American Hospital Formulary Service-Drug Information;
(b) Drug Facts and Comparisons;
(c) The American Dental Association Accepted
		  Dental Therapeutics; and
(d) The
		  United States Pharmacopoeia-Drug Information;
(5) Findings, studies or research conducted
		  by or under the auspices of federal government agencies and nationally
		  recognized federal research institutes, including:
(a) The federal Agency for Healthcare
		  Research and Quality;
(b) The
		  National Institutes of Health;
(c)
		  The National Cancer Institute;
(d)
		  The National Academy of Sciences;
(e) The Centers for Medicare & Medicaid
		  Services;
(f) The federal Food and
		  Drug Administration; and
(g) Any
		  national board recognized by the National Institutes of Health for the purpose
		  of evaluating the medical value of health care services; or
(6) Any other medical or
		  scientific evidence that is comparable to the sources listed in paragraphs (1)
		  through (5).
EE. "NAIC"
		  means the National Association of Insurance Commissioners.
FF. "Person" means an individual, a
		  corporation, a partnership, an association, a joint venture, a joint stock
		  company, a trust, an unincorporated organization, any similar entity or any
		  combination of the foregoing.
GG.
		  "Prospective review" means utilization review conducted prior to an admission
		  or a course of treatment.
HH.
		  "Protected health information" means health information:
(1) That identifies an individual who is the
		  subject of the information; or
(2)
		  With respect to which there is a reasonable basis to believe that the
		  information could be used to identify an individual.
II. "Randomized clinical trial" means a
		  controlled, prospective study of patients that have been randomized into an
		  experimental group and a control group at the beginning of the study with only
		  the experimental group of patients receiving a specific intervention, which
		  includes study of the groups for variables and anticipated outcomes over
		  time.
JJ. "Retrospective review"
		  means a review of medical necessity (or substantially equivalent term)
		  conducted after services have been provided to a patient, but does not include
		  the review of a claim that is limited to an evaluation of reimbursement levels,
		  veracity of documentation, accuracy of coding or adjudication for
		  payment.
KK. "Second opinion" means
		  an opportunity or requirement to obtain a clinical evaluation by a provider
		  other than the one originally making a recommendation for a proposed health
		  care service to assess the clinical necessity and appropriateness of the
		  initial proposed health care service.
LL. "Utilization review" means a set of
		  formal techniques designed to monitor the use of, or evaluate the clinical
		  necessity, appropriateness, efficacy, or efficiency of, health care services,
		  procedures, or settings. Techniques may include ambulatory review, prospective
		  review, second opinion, certification, concurrent review, case management,
		  discharge planning, or retrospective review.
MM. "Utilization review organization" means
		  an entity that conducts utilization review, other than a health carrier
		  performing a review for its own health benefit plans.