58-17C-34
Applicability of chapter 17C.
58-17C-35
Health
carrier responsibility for utilization review activities.
58-17C-36
Director
to hold health carrier responsible for utilization review
performance of contractor.
58-17C-37
Written
utilization review program required--Contents of program
document.
58-17C-38
Utilization review program to use documented clinical review
criteria--Criteria to be made available to authorized agencies
upon request.
58-17C-39
Program
to be administered by qualified licensed health care
professionals.
58-17C-40
Determinations to be issued in a timely manner--Process to
ensure consistency.
58-17C-40.1
Calculation of time period for determination for prospective and
retrospective reviews.
58-17C-41
Effectiveness and efficiency of program to be routinely
reviewed.
58-17C-42
Data
systems must support program activities and generate management
reports.
58-17C-43
Health
carrier oversight of delegated activities--Requirements.
58-17C-44
Utilization review to be coordinated with other medical
management activity of health carrier.
58-17C-45
Health
carrier to provide free access to review staff.
58-17C-46
Only
information necessary for review or determination to be
collected.
58-17C-47
Prohibition against compensation influencing or based upon
review decisions.
58-17C-48
Written
procedures required for making determinations--Notification.
58-17C-49
Prospective review determinations--Timing--Notification of
requirements-- Extension of time.
58-17C-50
Concurrent review determinations--Timing--Notification
requirements.
58-17C-51
Retrospective review determinations--Timing--Notification
requirements.
58-17C-52
Notification of adverse determination--Contents.
58-17C-53
Repealed.
58-17C-54
Information required to be provided to covered persons and
prospective covered persons.
58-17C-55
Certain
plans exempt from requirements of §§ 58-17C-34 to 58-17C-57,
inclusive.
58-17C-56
If
private accrediting body meets requirements, health carrier may
be deemed to have met them.
58-17C-57
Director
authorized to promulgate rules--Scope of rules.
58-17C-58
Establishment of grievance system by managed care plan or
utilization review organization.
58-17C-59
Record
of grievances--Report.
58-17C-60
Maintenance of grievance records--Accessibility.
58-17C-61, 58-17C-62.
Repealed.
58-17C-63
Promulgation of rules for grievance system.
58-17C-64
Registration of utilization review organizations--Required
information.
58-17C-65
Filing
changes in registration information.
58-17C-66
Requests
of information from utilization review organizations.
58-17C-67
Activities of nonregistered utilization review organizations
prohibited.
58-17C-68
Registration fee for utilization review organizations.
58-17C-69
Application of §§ 58-17C-58 to 58-17C-68, inclusive.
58-17C-70
"Urgent
care request" defined.
58-17C-71
Urgent
care requests--Written procedures for receipt and determination
of requests required.
58-17C-72
Urgent
care requests--Timely notification of determination.
58-17C-73
Insufficient information for determination--Notice and statement
of necessary information required.
58-17C-74
Insufficient information for determination of prospective urgent
care requests.
58-17C-75
Time
within which to submit necessary information.
58-17C-76
Urgent
care requests--Notice of determination--Failure to submit
necessary information grounds for denial of
certification--Notice of adverse determinations.
58-17C-77
Concurrent review urgent care requests--Requests for extended
care--Time to make determination and provide notice.
58-17C-78
Calculation of time periods for determinations.
58-17C-79
Notification of adverse determinations--Requirements.
58-17C-80
Register
of grievances required--Information to be compiled--Maintenance.
58-17C-81
Report
to director required--Contents of report.
58-17C-82
Grievance procedures--Filing with director required--Certificate
of compliance--Contact information required.
58-17C-83
Review
of adverse determinations--Time for filing--Designation and
notice of reviewers--Scope of review.
58-17C-84
Review
of adverse determinations--Rights of covered person or
authorized representative--Access to documentation.
58-17C-85
Review
of adverse determinations--Time for issuing decisions and
providing notice--Calculation of time periods.
58-17C-86
Issuance
of decision--Required contents.
58-17C-87
Health
carrier to establish review procedures for grievances not
involving adverse determinations.
58-17C-88
Standard
review--Covered persons or authorized representatives entitled
to submit written material only.
58-17C-89
Designation of person(s) to conduct standard review--Notice to
covered person or authorized representative.
58-17C-90
Standard
review--Time within which to notify covered person of decision--
Extension of time.
58-17C-91
Standard
review--Required contents of written decision.
58-17C-92
Additional voluntary review--Right of covered person to
appear--Required notice--Not applicable to health indemnity
plans.
58-17C-93
Additional voluntary review--Required notice--Rights of covered
person(s) or authorized representatives.
58-17C-94
Appointment of panel for voluntary review of first level review
decision--Scope of review--Composition of panel.
58-17C-95
Standard
review--Appointment of voluntary review panel--Composition of
panel.
58-17C-96
Procedures for appearance before voluntary review panel--Legal
representation--Time for issuance of decision.
58-17C-97
Notice
and issuance of decision when covered person does not request
appearance--Time for issuance of decision.
58-17C-98
Decision
by voluntary review panel--Required contents.
58-17C-99
Expedited review for adverse determinations involving urgent
care requests-- Appointment of peers for review.
58-17C-100
Expedited review not initial determination for
benefits--Transmission of necessary information.
58-17C-101
Expedited review decision not initial determination for
benefits--Time of notification--Continuation of service
involving concurrent review urgent care requests.
58-17C-102
Expedited review decision--Notification--Required contents.
58-17C-102.1
Applicability of §§ 58-17C-40 to 58-17C-102, inclusive.
58-17C-103
Promulgation of rules--Consistency with federal requirements.
