A. To assure confidentiality, a private review agent must, when contacting a physician's office or hospital, provide its certification number, the caller's name, and professional qualifications to the designated utilization review representative in the physician's office or hospital.

B. The entity providing utilization review will first contact the designated utilization review representative in the physician's office or hospital. Direct contact with the physician will be requested only when necessary information cannot be obtained from the designated representative. The designated utilization review representative must be reasonably available.

C. Any provider targeted for 100% concurrent review must be provided the reason, in writing, by the private review agent.

D. Only information necessary to complete the review process submitted under Part III will be collected.

E. An expedited appeal process shall be available. The physician of record shall have an opportunity to appeal that determination over the phone on an expedited basis. Utilization review organizations shall provide for reasonable access to their consulting physician(s) for such appeals.

F. Physician or designated utilization review representative shall be notified, as required by Federal Statute 18 U.S.C. S2511, when telephone conversations are being recorded and shall be provided a copy of the conversation upon request. The physician or utilization review representative who records any conversation with a private review agent shall have like responsibility.

G. Copies of denials shall be furnished at the request of the Director.

H. Concurrent review will be initiated at a reasonable length of time following admission and at reasonable intervals thereafter. Utilization review organizations will base the frequency of the review on the patient's medical condition. The attending physician and the hospital will be informed of the certified length of stay and the next anticipated review encounter.

I. A review will be conducted by a physician advisor on a determination not to certify a continued length of stay due to questions of medical necessity or appropriateness. A consulting physician will be reasonably available by telephone to discuss the medical basis for that determination with the attending physician (e.g., criteria, protocols, medical literature).

J. When a determination is made not to certify a continued length of stay, the utilization review organization will notify the physician and the hospital of this decision by telephone supplemented by written notification to the hospital, attending physician and patient. [FN1] This written notification will include an explanation of the principal reason(s) for the determination not to certify and the procedures to initiate an appeal of that determination if the patient so chooses.

K. If after an initial appeal or request of reconsideration, continued stay is not certified due to questions of medical necessity or appropriateness, the patient or provider will have the right to an additional review by another consulting physician of the appropriate medical specialty.