Louisiana Revised Statutes 22:2395 – Procedure for application to act as a utilization review organization
Terms Used In Louisiana Revised Statutes 22:2395
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:2392
- Contract: A legal written agreement that becomes binding when signed.
- entity: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. See Louisiana Revised Statutes 22:2392
- Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a health insurance issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Louisiana Revised Statutes 22:2392
- Health insurance issuer: means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including through a health benefit plan as defined in this Section, and shall include a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits. See Louisiana Revised Statutes 22:2392
- person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
- Utilization review: means a set of formal techniques designed to monitor the use of or evaluate the clinical or medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings. See Louisiana Revised Statutes 22:2392
- Utilization review organization: means a licensed entity that conducts utilization review in the internal claims and appeals process provided pursuant to Louisiana Revised Statutes 22:2392
A. Any applicant for licensure as a utilization review organization, other than a health insurance issuer, shall submit an application to the commissioner and pay the application fee specified in La. Rev. Stat. 22:821(B)(36). The application shall be on a form and accompanied by any supporting documentation required by the commissioner and shall be signed and verified by the applicant. The information required by the application shall include but not be limited to the following:
(1) The name of the entity operating as a utilization review organization and any trade or business names used by that entity in connection with making utilization review determinations.
(2) The names and addresses of every officer and director of the entity operating as a utilization review organization, the name and address of the corporate officer designated by the utilization review organization as the corporate representative to oversee the utilization review, and such biographical information as may be requested by the commissioner.
(3) The name and address of every person owning, directly or indirectly, ten percent or more of the entity operating as a utilization review organization as well as such biographical information as may be requested by the commissioner.
(4) The principal place of business of the utilization review organization.
(5) A general description of the operation of the utilization review organization which includes a statement that the utilization review organization does not engage in the practice of medicine or act to impinge upon or encumber the independent medical judgment of treating physicians or health care providers.
(6) A copy of the utilization review organization’s procedure manual which meets the requirements of this Chapter for making utilization review.
(7) A sample copy of any contract, absent fees charged, for making utilization review determinations that is entered into with a health insurance issuer, nonfederal government health benefit plan, or other group health plan.
(8) The names, addresses, and qualifications of individuals being designated to make utilization review determinations pursuant to this Chapter.
B. A health insurance issuer holding a valid certificate of authority to operate in this state may be authorized to act as a utilization review organization under the requirements of this Chapter following submission to the commissioner of appropriate documentation for review and approval that shall include but not be limited to the following:
(1) A general description of the operation of the utilization review organization which includes a statement that the utilization review organization does not engage in the practice of medicine or act to impinge upon or encumber the independent medical judgment of treating physicians or health care providers.
(2) A copy of the utilization review organization’s program description or procedures manual which meets the requirements of this Chapter for making clinical or medical necessity determinations and resolving disputes in the internal claims and appeals process.
(3) A sample copy of any contract, absent fees charged, for making utilization review determinations that is entered into with another health insurance issuer.
Acts 2013, No. 326, §1, eff. Jan. 1, 2015.