South Carolina Code of Regulations › Chapter 69 - DEPARTMENT OF INSURANCE › Section 69-47 - Private Review Agents

Current through Register Vol. 48, No. 6, June 28, 2024
I. Purpose.
The purpose of this regulation is to implement and enforce the
			 provisions and statutory requirements contained in Act 311 of 1990 and to
			 establish applicable fees and standards for private review agents operating in
			 South Carolina.
II.
		  Definitions.
For the purposes of this regulation, the following terms are
			 defined as:
A. "Appeal"--A request to
		  reconsider a determination not to certify an admission, procedure, extension of
		  stay or other health care service.
B. "Certificate"--Renewable certificate of
		  registration granted by the Commissioner to a private review agent, authorizing
		  the private review agent to perform utilization reviews in this State for two
		  years. This certificate is not transferable.
C. "Certification"--A determination by a
		  utilization review organization that an admission, extension of stay, or other
		  health care service has been reviewed and, based on the information provided,
		  meets the clinical requirements for medical necessity, appropriateness, level
		  of care or effectiveness under the applicable health benefit plan.
D. "Commissioner"--The Chief Insurance
		  Commissioner of South Carolina.
E.
		  "Discharge Planning"--The process of assessing a patient's need for treatment
		  after hospitalization to facilitate the necessary services and resources for an
		  appropriate and timely discharge.
F. "Health Care Provider"--Any attending
		  health care provider, facility or practitioner, authorized under state or
		  federal law to bill for health care services rendered.
G. "Other Party Designated"--Any person or
		  entity designated by the insured to receive notice of certification or denials
		  thereof. This term shall presumptively include the primary attending health
		  care provider and any other affected health care provider of record.
H. "Private Review Agent"--A corporation,
		  partnership, association or any other entity performing utilization reviews.
		  All private review agents not hereinafter exempt must obtain a certificate.
1. The State of South Carolina or any South
		  Carolina business entity which uses its employees to perform utilization
		  reviews on behalf of its employees or any hospital which performs utilization
		  reviews is not required to obtain a certificate, unless the hospital is
		  performing those reviews for a fee for an entity which is not owned or
		  affiliated with the hospital.
2.
		  Insurance companies, administrators of insurance benefit plans and health
		  maintenance organizations licensed and regulated by the Department which
		  perform utilization reviews are not required to obtain a certificate. However,
		  each of these entities must comply with Sections IV through XI of this
		  regulation.
3. Private review
		  agents performing utilization reviews only for single-employer, self-insured
		  employee health benefit plans are not required to obtain a
		  certificate.
4. Private review
		  agents performing utilization reviews only for health care services provided
		  pursuant to a federal law, which specifically preempts state regulation, are
		  not required to obtain a certificate.
I. "Utilization Criteria"--The written
		  policies, rules, medical protocols, or guides used by the private review agent
		  to review, grant or deny certification.
J. "Utilization Review"--A system for
		  reviewing the necessary, appropriate, and efficient allocation of health care
		  resources and services given or proposed to be given to a patient or group of
		  patients.