Maine Revised Statutes Title 24-A Sec. 4228 – Utilization review data
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1. Report required. On or before April 1st of each year, each health maintenance organization which issues a program of contract in this State that contains a provision whereby in nonemergency cases the insured is required to be prospectively evaluated through a prehospital admission certification, preinpatient service eligibility program or any similar preutilization review or screening procedure prior to the delivery of contemplated hospitalization, inpatient or outpatient health care or medical services which are prescribed or ordered by a duly licensed physician shall file a report on the results of that evaluation for the preceding year with the superintendent which shall contain the following:
A. The number and type of evaluations performed.
(1) For the purposes of this section, the term “type of evaluations” means the following preutilization review categories: presurgical inpatient days; setting of medical service, such as inpatient or outpatient services; and the number of days of service.
(2) The report must separately identify the number of evaluations performed in which the health care services requested or provided include chiropractic services and the results of those evaluations; [PL 1993, c. 669, §5 (AMD).]
B. The result of the evaluation, such as whether the medical necessity of the level of service contemplated by the patient’s physician was agreed to or whether benefits paid for the service were reduced by the health maintenance organization; [PL 1987, c. 168, §5 (NEW).]
C. The number and result of any appeals by patients or their physicians as a result of initial review decisions to reduce benefits for services as determined through prospective evaluations; and [PL 1987, c. 168, §5 (NEW).]
D. Any complaints filed in a court of competent jurisdiction and served upon a health maintenance organization filing under this section stating a cause of action against that organization on the basis of damages to patients alleged to have been proximately caused by a delay, reduction or denial of medical benefits by the organization, as determined through prospective evaluations, and the determination of liability or other disposition of the complaint. [PL 1987, c. 168, §5 (NEW).]
[PL 1993, c. 669, §5 (AMD).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 4228
- Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
- Contract: A legal written agreement that becomes binding when signed.
- Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
- Health care services: means any services included in the furnishing of medical care, dental care or hospitalization to an individual, or any services incident to the furnishing of that care or hospitalization, as well as the furnishing of any other services to an individual to prevent, alleviate, cure or heal human illness or injury. See Maine Revised Statutes Title 24-A Sec. 4202-A
- Health maintenance organization: means a public or private organization that is organized under the laws of the Federal Government, this State, another state or the District of Columbia or a component of such an organization, and that:
A. See Maine Revised Statutes Title 24-A Sec. 4202-AJurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases. Superintendent: means the Superintendent of Insurance. See Maine Revised Statutes Title 24-A Sec. 4202-A Year: means a calendar year, unless otherwise expressed. See Maine Revised Statutes Title 1 Sec. 72
2. Maine residents. This section is applicable to evaluations, appeals and complaints relating to Maine residents only.
[PL 1987, c. 168, §5 (NEW).]
3. Confidentiality. Any information provided pursuant to this section shall not identify the names of patients.
[PL 1987, c. 168, §5 (NEW).]
SECTION HISTORY
PL 1987, c. 168, §5 (NEW). PL 1993, c. 669, §5 (AMD).