W. Va. Code R. § 114-56-6

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 114-56-6 - Utilization Management Program

6.1. A prepaid limited health service organization shall have a documented utilization management program which 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 limited health services.

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

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

a. A prepaid limited health service organization shall have criteria for appropriateness of a limited health service clearly documented and available, upon request, to participating physicians.

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

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

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

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

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

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

6.4. Decisions regarding provision of limited health services shall be made in a timely manner depending upon the urgency of the situation.

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

b. In those instances in which a prepaid limited health service organization denies limited health 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 coordinating provider, and the facility, if appropriate.

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

6.5. A prepaid limited health service organization may have policies and procedures in place to evaluate the appropriate use of new medical technologies, or new application 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, 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.

6.6. A prepaid limited health service organization shall have mechanisms to evaluate the effects of the program using member satisfaction data, provider satisfaction data and other appropriate means.

W. Va. Code R. § 114-56-6