W. Va. Code R. § 114-51-4

Current through Register Vol. XLI, No. 49, December 6, 2024

Section 114-51-4 - Requirements of Utilization Management Program

4.1. A health maintenance organization shall develop a utilization management (UM) program which adheres to all applicable state and federal laws, federal regulations and state rules.

4.2. Each application for a certificate of authority or renewal thereof filed with the commissioner pursuant to the Health Maintenance Organization Act, W. Va. Code ' 33-25A-1 et seq., shall be accompanied by a description of the health maintenance organization's utilization management program, which shall include, but not be limited to, the requirements of the utilization management program set forth in this rule.

a. Pursuant to the requirements of W. Va. Code '33-25A-3, a health maintenance organization shall file notice with the commissioner prior to any modification of the utilization management program.

4.3. A health maintenance organization shall have a documented utilization management program description that describes both delegated and non-delegated activities.

a. The UM program description shall include, at a minimum, performance goals, policies and procedures to evaluate medical necessity, criteria used, information sources, and the process used to review and approve the provision of medical services.

b. The UM program shall have a mechanism for evaluating and updating the program description on a periodic basis which shall be specified by the health maintenance organization.

4.4. If a health maintenance organization delegates any UM activities to contractors, there shall be evidence of oversight of the contracted entity.

a. The health maintenance organization shall maintain a written description of:

1. The delegated activities;

2. The contractor's accountability for these activities;

3. The frequency of reporting to the health maintenance organization; and

4. The process by which the delegation will be evaluated.

b. The health maintenance organization shall maintain evidence of:

1. Approval of the contractor's UM program; and

2. Evaluation of regular UM reports from the contractor.

c. The health maintenance organization shall be responsible for monitoring the activities of the entity to which it delegates UM activities and for ensuring that the requirements of this rule are met.

4.5. Each health maintenance organization shall have written procedures for assuring that patient-specific information obtained during any UM activity will be:

a. Kept confidential in accordance with applicable federal and state laws; and

b. Used solely for the purposes of utilization management, in addition to quality assurance, discharge planning and catastrophic case management.

4.6. The UM program shall have written utilization review decision protocols based on reasonable medical evidence.

a. A health maintenance organization shall have criteria for appropriateness of medical services clearly documented and available, upon request, to participating physicians.

b. A health maintenance organization shall establish a mechanism for checking the consistency of the application of criteria utilized by reviewers.

c. A health maintenance organization shall establish a mechanism for updating review criteria on a periodic basis which shall be specified by the health maintenance organization.

4.7. The UM program shall have professionally accepted, pre-established criteria for the preauthorization of services and for concurrent review of admissions.

a. A health maintenance organization shall, on a timely basis, make efforts to obtain all necessary information, including pertinent clinical information, and consultation with the treating physician, as appropriate.

b. Qualified medical professionals shall review decisions for preauthorization of medical services and concurrent review of admissions.

c. A duly licensed physician shall conduct a review of medical appropriateness on any denial of medical services.

d. At any point during the review process, a licensed physician consultant specially trained in the area of medicine in question shall be available to provide his or her expert opinion regarding medical appropriateness and necessity of medical services whenever necessary.

4.8. Decisions regarding provision of medical services shall be made in a timely manner depending upon the urgency of the situation.

a. The health maintenance organization shall establish medically appropriate time frames for urgent, emergency and planned care cases.

b. In those instances in which a health maintenance organization denies medical services, a written notice of denial shall be sent immediately to all involved parties, which shall include, but not be limited to, the subscriber, the primary care physician, and the facility, if appropriate.

1. The written notice of denial shall include the reason for denial and an explanation of the appeal process.

4.9. A health maintenance organization may have policies and procedures in place to evaluate the appropriate use of new medical technologies, or new applications of established technologies, including medical procedures, drugs, and devices. Any policies and procedures in place regarding new medical technologies shall include standards requiring:

a. Appropriate professionals to participate in the development of technology evaluation criteria;

b. The review of information from appropriate health-related government agencies and/or government regulatory bodies and published scientific evidence;

c. Assessment of new technologies and new applications of existing technologies; and

d. Periodic evaluation and update of policies and procedures as technologies and procedures expand and change.

4.10. A health maintenance organization shall have mechanisms to evaluate the effects of the program using member satisfaction data, provider satisfaction data, and/or other appropriate means.

W. Va. Code R. § 114-51-4