Chapter 17H - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS

Section 58-17H-1 - Definitions
Section 58-17H-2 - Health benefit plan defined
Section 58-17H-3 - Urgent care request defined
Section 58-17H-4 - Applicability of chapter
Section 58-17H-5 - Health carrier to provide emergency services coverage without requiring prior authorization-Standards for coverage of emergency services
Section 58-17H-6 - In-network emergency services
Section 58-17H-7 - Cost-sharing requirements for out-of-network emergency services
Section 58-17H-8 - Cost-sharing requirements for covered persons-Payments to out-of-network providers
Section 58-17H-9 - Exceptions for payments by capitated and other plans without negotiated fees
Section 58-17H-10 - Negotiated amounts for in-network providers for a particular emergency service
Section 58-17H-11 - General cost-sharing requirements allowed
Section 58-17H-12 - Access to representative for post-evaluation or post-stabilization services
Section 58-17H-13 - Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body
Section 58-17H-14 - Health carrier responsibility for utilization review activities
Section 58-17H-15 - Director to hold health carrier responsible for utilization review performance of contractor
Section 58-17H-16 - Written utilization review program required-Contents of program document
Section 58-17H-17 - Utilization review program to use documented clinical review criteria-Criteria to be available to authorized agencies upon request
Section 58-17H-18 - Program to be administered by qualified licensed health care professionals
Section 58-17H-19 - Determinations to be issued in timely manner-Process to ensure consistency
Section 58-17H-20 - Effectiveness and efficiency of program to be routinely reviewed
Section 58-17H-21 - Data systems to support program activities and generate management reports
Section 58-17H-22 - Health carrier oversight of delegated activities-Requirements
Section 58-17H-23 - Utilization review to be coordinated with other medical management activity of health carrier
Section 58-17H-24 - Health carrier to provide free access to review staff
Section 58-17H-25 - Only information necessary for review or determination to be collected
Section 58-17H-26 - Independence and impartiality required for utilization review
Section 58-17H-27 - Written procedures required for making determinations-Notification
Section 58-17H-28 - Prospective review determinations-Timing-Notification of requirements-Extension of time
Section 58-17H-29 - Concurrent review determinations-Timing-Notification requirements
Section 58-17H-30 - Retrospective review determinations-Timing-Notification requirements
Section 58-17H-31 - Calculation of time period for determination for prospective and retrospective reviews
Section 58-17H-32 - Notification of adverse determination-Contents
Section 58-17H-33 - Information required to be provided to covered persons and prospective covered persons
Section 58-17H-34 - Health carrier may be deemed to meet utilization review requirements if met by private accrediting body
Section 58-17H-35 - Registration of utilization review organizations-Required information
Section 58-17H-36 - Filing changes in registration information
Section 58-17H-37 - Requests for information from utilization review organizations
Section 58-17H-38 - Activities of nonregistered utilization review organizations prohibited
Section 58-17H-39 - Registration fee for utilization review organizations
Section 58-17H-40 - Urgent care requests-Written procedures required for receipt and determination of requests
Section 58-17H-41 - Insufficient information for determination-Notice and statement of necessary information
Section 58-17H-42 - Insufficient information for determination of prospective urgent care requests
Section 58-17H-43 - Urgent care requests-Timely notification of determination
Section 58-17H-44 - Time within which to submit necessary information
Section 58-17H-45 - Urgent care requests-Notice of determination-Failure to submit necessary information as grounds for denial of certification
Section 58-17H-46 - Concurrent review urgent care requests-Extended care requests-Time for determination and notice
Section 58-17H-47 - Calculation of time periods for determination
Section 58-17H-48 - Notification of adverse determination-Requirements
Section 58-17H-49 - Promulgation of rules
Section 58-17H-50 - Coverage for cancer treatment medication
Section 58-17H-51 - Reclassification of benefits with respect to cancer treatment medications
Section 58-17H-52 - Medical management practices complying with chapter
Section 58-17H-53 - Step therapy protocols
Section 58-17H-54 - Step therapy protocols-Process-Transparency
Section 58-17H-55 - Step therapy override exceptions
Section 58-17H-56 - Limitations