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007.05.5-3. PRIVATE REVIEW AGENTS - APPLICATION FOR CERTIFICATION

AR ADC 007.05.5-3Arkansas Administrative Code

West's Arkansas Administrative Code
Title 007. Department of Health
Division 05. Health Facility Services
Rule 5. Rules and Regulations for Utilization Review in Arkansas
Ark. Admin. Code 007.05.5-3
007.05.5-3. PRIVATE REVIEW AGENTS - APPLICATION FOR CERTIFICATION
Currentness
A. By December 31, 1990 or a date approved by the Director, a private review agent shall hold a certificate from the Director to conduct utilization review in this State.
B. A private review agent seeking certification shall:
1. Submit an application to the Director in a form that the Director requires;
2. Pay an application fee of $1,250 per year. This fee is payable in advance for both years of the certification (total $2,500). This fee applies to the entity doing the review and not to the individual reviewer;
3. Provide supporting documentation as required by this regulation.
C. An application for certification shall be accompanied by all of the following:
1. A utilization review plan which shall include any or all of the following components used by the private review agent to approve or deny payment or recommend approval or denial of payment in advance for proposed or delivered inpatient or outpatient care or retrospectively approve or deny under certain circumstances.
a. Elements of review such as:
1. Prospective review (includes preadmission, admission and preauthorization)
2. Concurrent or continued stay review;
3. Reconsideration;
4. Second surgical opinion;
5. Non-certification or non-authorization;
6. Lack of information or administrative denial;
7. Retrospective review;
8. Bill review.
b. Policies and procedures for review including:
1. Any forms or form letters used during the review process;
2. Time frames that shall be met during the review;
3. A written protocol describing every aspect of the review process.
c. A description of the clinical review criteria and the policies and procedures for updating or modification.
d. Review delegation and oversight policies and procedures.
e. The provisions, procedures, and time frames by which patients, physicians, or hospitals may seek appeal of an adverse determination by the private review agent including:
1. A written protocol describing the appeal procedure;
2. Any forms or form letters which shall be used during the appeal procedure;
3. Time frames that shall be met during the appeal procedure;
4. The names and qualifications of personnel making final appeal determinations.
f. Quality management program policies and procedures;
g. Case management policies and procedures.
2. The name, number, type and qualification or qualifications of the personnel either employed or under contract to perform the utilization review. Any change in the medical director shall be reported to the Director within 30 days
3. Policies and procedures to verify the current licensure and credentials of utilization review personnel, consulting and appeal physicians, chiropractic physicians, and dentists.
4. Policies and procedures to ensure that a representative of the private review agent is accessible to patients and providers five days a week during normal business hours in this State; and that a free telephone number be provided with adequate lines available and staffed. The procedure for handling after-hours, weekend and holiday inquires shall be specified.
5. The policies and procedures to ensure that all applicable State and Federal laws to protect the privacy, security and confidentiality of individual health information are followed.
6. A copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan.
7. A list of the health plans, health insurers, third party payers or others for which the private review agent is performing utilization review in this State.
D. A certificate of registration is not transferable.
E. The application information and all supporting documents as provided by Act 537 shall be held in confidence and not disclosed to the public.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 007.05.5-3, AR ADC 007.05.5-3
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