Section Ins 2001.17 - Other Provisions(a) A prerequisite for the licensing of a medical utilization review entity shall be accreditation of the utilization review services performed by the utilization review entity from the URAC or the NCQA.(b) A licensed medical utilization review entity shall allow any licensed facility rendering service, physician, or responsible beneficiary representative, including a family member, to assist in fulfilling any certification or other managed care requirement.(c) Any written procedures maintained in order to comply with the standards of the URAC or the NCQA by a licensed medical utilization review entity shall be made available to the insurance department upon the department's written request.(d) No claim for benefits shall be denied nor shall any payment be reduced on the basis of an adverse medical utilization review determination unless the beneficiary is given notice of the right to appeal. The notice shall contain an explanation of the appeals process that shall be sufficient to enable the beneficiary to effectively exercise the right of appeal.(e) A denial or reduction of benefits based on the failure of a provider to supply the medical utilization review entity with complete information shall describe in detail the information required but not received by the medical utilization review entity.N.H. Admin. Code § Ins 2001.17
#5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10
Amended by Volume XXXVIII Number 28, Filed July 12, 2018, Proposed by #12545, Effective 6/11/2018, Expires 6/11/2028.