South Carolina Code 38-70-20. Certificate to perform activities; applications; fees; minimum standards; confidentiality of records
(B) An applicant for a certificate shall pay the director or his designee the application fee as provided in § 38-70-50 and shall submit an application to the director or his designee on forms and with any supporting documentation that the director or his designee requires. The application must contain information regarding the utilization review programs to be conducted by the applicant which must meet the requirements contained in subsection (C).
Terms Used In South Carolina Code 38-70-20
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Certificate: means a renewable certificate of registration granted by the director or his designee to a private review agent, authorizing the agent to perform utilization review activities in this State for two years. See South Carolina Code 38-70-10
- Contract: A legal written agreement that becomes binding when signed.
- Director: means the person who is appointed by the Governor upon the advice and consent of the Senate and who is responsible for the operation and management of the department. See South Carolina Code 38-1-20
- Director or his designee: means the director or his designee of the South Carolina Department of Insurance. See South Carolina Code 38-70-10
- Private review agent: means a person performing utilization reviews who is either under contract with or acting on behalf of, but not employed by:
(a) a South Carolina business entity;
(b) the State of South Carolina; or
(c) a hospital. See South Carolina Code 38-70-10 - Utilization review: means 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. See South Carolina Code 38-70-10
- Utilization review program: means an overview of the activities performed by the private review agent. See South Carolina Code 38-70-10
(C) A utilization review program of the applicant must meet the following minimum standards:
(1) notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within five business days;
(2) all utilization review agents shall maintain a procedure by which insured or providers may seek reconsideration of appeal of determinations of the utilization review agent;
(3) a representative of the utilization review agent must be accessible by telephone to insureds or providers in South Carolina, at least forty hours each week during normal business hours;
(4) the type and qualification of the personnel either employed or under contract to perform the utilization reviews must be included in the utilization review program information submitted to the director or his designee;
(5) a copy of the materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan must be provided interested parties upon request; and
(6) an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed.