90- 351 C.M.R. ch. 7, § 1

Current through 2024-44, October 30, 2024

Section 351-7-1 - Certification

1. An entity may conduct utilization review only if that entity is certified by the Board.

2. An Insurer, Self-Insurer or Group Self-Insurer which contracts with another entity to perform utilization review activities, maintains full responsibility for compliance with Maine Workers' Compensation law and Board Rules.

3. To become certified by the Board, the entity shall show proof of one the following by attaching the appropriate documentation:

A.Unconditional Certification: Accreditation by the Utilization Review Accreditation Commission (URAC) under URAC's National Workers' Compensation Utilization Management Standards by providing a copy of the Certificate of Accreditation and any other documents/information as requested by the Board; or

B.Conditional Certification: Verification that an Application for Accreditation under URAC's National Workers' Compensation Utilization Management Standards has been submitted to URAC by providing a copy of the URAC confirmation letter indicating the application is under review and any other documents/information as requested by the Board.

(1) The entity requesting Board certification shall advise the Board if the URAC application is withdrawn or denied. Withdrawal or denial of the URAC application shall result in immediate revocation of Board certification.

(2) Within six months of applying for a Conditional Certification, an entity must submit proof of accreditation as outlined in A above and achieve Unconditional Certification. If proof of accreditation is not provided, immediate revocation of Board certification will result. Entities may re-apply for Board certification as outlined in this Chapter at any time.

4. An Unconditional Board certification shall expire for entities upon the date of their URAC certification expiration date unless proof that URAC certification has been renewed and the new expiration date is provided.

5. The Board may at any time revoke certification to perform Utilization Review upon findings that an entity is not in compliance with any portion of 39-A M.R.S.A. §210 or Workers' Compensation Board Rule Chapter 7.

6. The Board may at any time request case records for purposes of investigating Insurers/Utilization Review Agents compliance with 39-A M.R.S.A. §210 and Board Rules.

7. The Board shall make available the list of entities certified by the Board to perform utilization review activities.

90- 351 C.M.R. ch. 7, § 1