Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-8 - Adverse Health Care Treatment Decisions

Current through 2024-29, July 17, 2024
In addition to the requirements of Title 24-A, Chapter 34,
				  any health carrier that provides or performs utilization review services, and
				  any designee of the health carrier or URE that performs utilization review
				  functions on the carrier's behalf, is subject to the requirements of this
				  section. The requirements of this section are applicable to all "adverse health
				  care treatment decisions" rendered by or on behalf of "carriers."
A.
Corporate Oversight of Utilization
				Review Program
A health carrier shall be responsible for monitoring all
				  utilization review activities carried out by or on its behalf, and for
				  compliance with the requirements of this. The health carrier shall also ensure
				  that, consistent with the requirements of Title
				  24-A M.R.S.A.
				  §4304(1), appropriate
				  personnel have operational responsibility for the conduct of the health
				  carrier's utilization review program.
B.
Contracting
Whenever a health carrier contracts to have a URE perform
				  the utilization review functions required by this rule, the Superintendent
				  shall hold the health carrier responsible for monitoring the activities of the
				  utilization review entity with which it contracts and for ensuring that the
				  requirements of this rule are met.
C.
Written Utilization Review
				Program
A health carrier that provides or performs utilization
				  review shall implement a written utilization review program that, consistent
				  with the requirements of Title
				  24-A M.R.S.A.
				  §2771(3) and this rule,
				  shall comprehensively describe all utilization review activities and
				  procedures, both delegated and non-delegated, applicable to any of its health
				  plans. The utilization review program must be consistent with the requirements
				  of this section.
D.
Operational Requirements
1) A
				utilization review program shall use documented clinical review criteria that
				are based on published sound clinical evidence and which are evaluated
				periodically to assure ongoing efficacy. A health carrier or the carrier's
				designated URE may develop its own clinical review criteria or may purchase or
				license clinical review criteria from qualified vendors. Upon request, a health
				carrier or the carrier's designated URE shall make available its clinical
				review criteria to the Superintendent and the Commissioner of the Department of
				Human Services.
2) Qualified health
				care professionals shall administer the utilization review program and oversee
				review decisions. A clinical peer shall evaluate the clinical appropriateness
				of adverse health care treatment decisions.
3) A health carrier or the carrier's
				designated URE shall issue utilization review decisions in a timely manner
				pursuant to the requirements of subsections F, G, G-1, and H.
a) A health carrier or the carrier's
				designated URE shall obtain all information required to make a utilization
				review decision, including pertinent clinical information.
b) A health carrier or the carrier's
				designated URE shall have a process to ensure that utilization reviewers apply
				clinical review criteria consistently.
4) A health carrier or the carrier's
				designated URE shall routinely assess the effectiveness and efficiency of its
				utilization review program.
5) A
				health carrier's or the carrier's designated URE's data systems shall be
				sufficient to support utilization review program activities and to generate
				management reports to enable the health carrier or the carrier's designated URE
				to monitor and manage health care services effectively.
6) If a health carrier delegates any
				utilization review activities to a URE, the health carrier shall maintain
				adequate oversight, which shall include:
a) A
				written description of the URE's activities and responsibilities, including
				reporting requirements;
b) Evidence
				of formal approval of the URE program by the health carrier; and
c) A process by which the health carrier
				evaluates the performance of the URE.
7) A health carrier or the carrier's
				designated URE shall provide covered persons and participating providers with
				access to its review staff by a toll-free number or collect call phone line.
				Telephone lines must be adequately staffed to provide providers and covered
				persons ready access to staff performing utilization review
				functions.
8) When conducting
				utilization review, the health carrier or the carrier's designated URE shall
				collect only the information necessary to certify the admission, procedure or
				treatment, length of stay, frequency and duration of services. The requirements
				of this subsection shall not be construed to prevent a carrier from collecting
				data for quality assurance purposes.
9) Compensation to persons providing
				utilization review services for a health carrier or the carrier's designated
				URE may not be based on the quantity of adverse health care treatment decisions
				rendered, or otherwise include incentives for reviewers to render inappropriate
				review decisions.