Maine Revised Statutes Title 24 Sec. 2343 – Minimum standards
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A utilization review program of the applicant must meet the following minimum standards. [PL 1989, c. 556, Pt. C, §1 (NEW).]
1. Notification of adverse decisions. Notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within a time period to be determined by the superintendent through rulemaking.
[PL 1989, c. 556, Pt. C, §1 (NEW).]
Terms Used In Maine Revised Statutes Title 24 Sec. 2343
- medical utilization review services: means a program or process by which a person, partnership or corporation, on behalf of an insurer, nonprofit service organization, 3rd-party administrator, or health maintenance organization, preferred provider organization or employer that is a payor for or that arranges for payment of medical services, seeks to review the utilization, appropriateness or quality of medical services provided to a person whose medical services are paid for, partially or entirely, by that insurer, nonprofit service organization, 3rd-party administrator, health maintenance organization, preferred provider organization or employer. See Maine Revised Statutes Title 24 Sec. 2344
- superintendent: means the Superintendent of Insurance of this State; and
2. Reconsideration of determination. All licensees shall maintain a procedure by which insureds, patients or providers may seek reconsideration of determinations of the licensee.
[PL 1989, c. 556, Pt. C, §1 (NEW).]
3. Accessibility of representatives. A representative of the licensee must be accessible by telephone to insureds, patients or providers and the superintendent may adopt standards of accessibility by rule.
[PL 1989, c. 556, Pt. C, §1 (NEW).]
4. Information materials; confidentiality. 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 and an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed must be filed with the bureau.
[PL 1989, c. 556, Pt. C, §1 (NEW).]
5. Prohibited activities. A medical utilization review entity shall ensure that an employee does not perform medical utilization review services involving a health care provider or facility in which that employee has a financial interest.
[PL 1993, c. 602, §2 (NEW).]
SECTION HISTORY
PL 1989, c. 556, §C1 (NEW). PL 1993, c. 602, §2 (AMD).