Missouri Revised Statutes
Chapter 376
Life, Health and Accident Insurance
←376.1361
Section 376.1363.1
376.1365→
August 28, 2015
Utilization review decisions, procedures.
376.1363. 1. A health carrier shall maintain written procedures for
making utilization review decisions and for notifying enrollees and
providers acting on behalf of enrollees of its decisions. For purposes of
this section, "enrollee" includes the representative of an enrollee.
2. For initial determinations, a health carrier shall make the
determination within thirty-six hours, which shall include one working day,
of obtaining all necessary information regarding a proposed admission,
procedure or service requiring a review determination. For purposes of
this section, "necessary information" includes the results of any
face-to-face clinical evaluation or second opinion that may be required:
(1) In the case of a determination to certify an admission, procedure
or service, the carrier shall notify the provider rendering the service by
telephone or electronically within twenty-four hours of making the initial
certification, and provide written or electronic confirmation of a
telephone or electronic notification to the enrollee and the provider
within two working days of making the initial certification;
(2) In the case of an adverse determination, the carrier shall notify
the provider rendering the service by telephone or electronically within
twenty-four hours of making the adverse determination; and shall provide
written or electronic confirmation of a telephone or electronic
notification to the enrollee and the provider within one working day of
making the adverse determination.
3. For concurrent review determinations, a health carrier shall make
the determination within one working day of obtaining all necessary
information:
(1) In the case of a determination to certify an extended stay or
additional services, the carrier shall notify by telephone or
electronically the provider rendering the service within one working day of
making the certification, and provide written or electronic confirmation to
the enrollee and the provider within one working day after telephone or
electronic notification. The written notification shall include the number
of extended days or next review date, the new total number of days or
services approved, and the date of admission or initiation of services;
(2) In the case of an adverse determination, the carrier shall notify
by telephone or electronically the provider rendering the service within
twenty-four hours of making the adverse determination, and provide written
or electronic notification to the enrollee and the provider within one
working day of a telephone or electronic notification. The service shall
be continued without liability to the enrollee until the enrollee has been
notified of the determination.
4. For retrospective review determinations, a health carrier shall
make the determination within thirty working days of receiving all
necessary information. A carrier shall provide notice in writing of the
carrier's determination to an enrollee within ten working days of making
the determination.
5. A written notification of an adverse determination shall include
the principal reason or reasons for the determination, the instructions for
initiating an appeal or reconsideration of the determination, and the
instructions for requesting a written statement of the clinical rationale,
including the clinical review criteria used to make the determination. A
health carrier shall provide the clinical rationale in writing for an
adverse determination, including the clinical review criteria used to make
that determination, to any party who received notice of the adverse
determination and who requests such information.
6. A health carrier shall have written procedures to address the
failure or inability of a provider or an enrollee to provide all necessary
information for review. In cases where the provider or an enrollee will
not release necessary information, the health carrier may deny
certification of an admission, procedure or service.
(L. 1997 H.B. 335, A.L. 2013 S.B. 262, A.L. 2014 S.B. 716)
2013
1997
2013
376.1363. 1. A health carrier shall maintain written procedures for
making utilization review decisions and for notifying enrollees and
providers acting on behalf of enrollees of its decisions. For purposes of
this section, "enrollee" includes the representative of an enrollee.
2. For initial determinations, a health carrier shall make the
determination within two working days of obtaining all necessary
information regarding a proposed admission, procedure or service requiring
a review determination. For purposes of this section, "necessary
information" includes the results of any face-to-face clinical evaluation
or second opinion that may be required:
(1) In the case of a determination to certify an admission, procedure
or service, the carrier shall notify the provider rendering the service by
telephone or electronically within twenty-four hours of making the initial
certification, and provide written or electronic confirmation of a
telephone or electronic notification to the enrollee and the provider
within two working days of making the initial certification;
(2) In the case of an adverse determination, the carrier shall notify
the provider rendering the service by telephone or electronically within
twenty-four hours of making the adverse determination; and shall provide
written or electronic confirmation of a telephone or electronic
notification to the enrollee and the provider within one working day of
making the adverse determination.
3. For concurrent review determinations, a health carrier shall make
the determination within one working day of obtaining all necessary
information:
(1) In the case of a determination to certify an extended stay or
additional services, the carrier shall notify by telephone or
electronically the provider rendering the service within one working day of
making the certification, and provide written or electronic confirmation to
the enrollee and the provider within one working day after telephone or
electronic notification. The written notification shall include the number
of extended days or next review date, the new total number of days or
services approved, and the date of admission or initiation of services;
(2) In the case of an adverse determination, the carrier shall notify
by telephone or electronically the provider rendering the service within
twenty-four hours of making the adverse determination, and provide written
or electronic notification to the enrollee and the provider within one
working day of a telephone or electronic notification. The service shall
be continued without liability to the enrollee until the enrollee has been
notified of the determination.
4. For retrospective review determinations, a health carrier shall
make the determination within thirty working days of receiving all
necessary information. A carrier shall provide notice in writing of the
carrier's determination to an enrollee within ten working days of making
the determination.
5. A written notification of an adverse determination shall include
the principal reason or reasons for the determination, the instructions for
initiating an appeal or reconsideration of the determination, and the
instructions for requesting a written statement of the clinical rationale,
including the clinical review criteria used to make the determination. A
health carrier shall provide the clinical rationale in writing for an
adverse determination, including the clinical review criteria used to make
that determination, to any party who received notice of the adverse
determination and who requests such information.
6. A health carrier shall have written procedures to address the
failure or inability of a provider or an enrollee to provide all necessary
information for review. In cases where the provider or an enrollee will
not release necessary information, the health carrier may deny
certification of an admission, procedure or service.
1997
376.1363. 1. A health carrier shall maintain written procedures for
making utilization review decisions and for notifying enrollees and providers
acting on behalf of enrollees of its decisions. For purposes of this section,
"enrollee" includes the representative of an enrollee.
2. For initial determinations, a health carrier shall make the
determination within two working days of obtaining all necessary information
regarding a proposed admission, procedure or service requiring a review
determination. For purposes of this section, "necessary information" includes
the results of any face-to-face clinical evaluation or second opinion that may
be required:
(1) In the case of a determination to certify an admission, procedure or
service, the carrier shall notify the provider rendering the service by
telephone within twenty-four hours of making the initial certification, and
provide written or electronic confirmation of the telephone notification to
the enrollee and the provider within two working days of making the initial
certification;
(2) In the case of an adverse determination, the carrier shall notify
the provider rendering the service by telephone within twenty-four hours of
making the adverse determination; and shall provide written or electronic
confirmation of the telephone notification to the enrollee and the provider
within one working day of making the adverse determination.
3. For concurrent review determinations, a health carrier shall make the
determination within one working day of obtaining all necessary information:
(1) In the case of a determination to certify an extended stay or
additional services, the carrier shall notify by telephone the provider
rendering the service within one working day of making the certification, and
provide written or electronic confirmation to the enrollee and the provider
within one working day after the telephone notification. The written
notification shall include the number of extended days or next review date,
the new total number of days or services approved, and the date of admission
or initiation of services;
(2) In the case of an adverse determination, the carrier shall notify by
telephone the provider rendering the service within twenty-four hours of
making the adverse determination, and provide written or electronic
notification to the enrollee and the provider within one working day of the
telephone notification. The service shall be continued without liability to
the enrollee until the enrollee has been notified of the determination.
4. For retrospective review determinations, a health carrier shall make
the determination within thirty working days of receiving all necessary
information. A carrier shall provide notice in writing of the carrier's
determination to an enrollee within ten working days of making the
determination.
5. A written notification of an adverse determination shall include the
principal reason or reasons for the determination, the instructions for
initiating an appeal or reconsideration of the determination, and the
instructions for requesting a written statement of the clinical rationale,
including the clinical review criteria used to make the determination. A
health carrier shall provide the clinical rationale in writing for an adverse
determination, including the clinical review criteria used to make that
determination, to any party who received notice of the adverse determination
and who requests such information.
6. A health carrier shall have written procedures to address the failure
or inability of a provider or an enrollee to provide all necessary information
for review. In cases where the provider or an enrollee will not release
necessary information, the health carrier may deny certification of an
admission, procedure or service.
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