Section 3 AAC 28.906 - Scope and content of utilization review program(a) A health care insurer that requires utilization review of a benefit request under a health care insurance policy shall develop and implement a written utilization review program that describes, at a minimum, the following utilization review activities: (1) filing of a benefit request;(2) notification to a covered person or the covered person's authorized representative of a utilization review and benefit determination;(3) review of an adverse determination under 3 AAC 28.930 - 3 AAC 28.938, (b) The written document required under (a) of this section must describe (1) procedures to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services;(2) data sources and clinical review criteria used in making a determination;(3) procedures to ensure consistent application of clinical review criteria and compatible determinations;(4) data collection processes and analytical methods used to assess utilization of health care services;(5) provisions to ensure the confidentiality of clinical, proprietary, and protected health information;(6) the health care insurer's organizational mechanism, such as a utilization review committee or quality assurance or other committee, that periodically assesses the health care insurer's utilization review program and reports to the health care insurer's governing body; and(7) the position title for the health care insurer's staff member that is responsible for the day-to-day management of the utilization review program.Eff. 3/15/2018,Register 225, April 2018Authority:AS 21.06.090
AS 21.07.005