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Section 58-17H-1 - Definitions. - 58-17H-1. Definitions. Terms used in this chapter mean: (1)"Adverse determination,"...
Section 58-17H-2 - Health benefit plan defined. - 58-17H-2. Health benefit plan defined. For the purposes of this...
Section 58-17H-3 - Urgent care request defined. - 58-17H-3. Urgent care request defined. For the purposes of this...
Section 58-17H-4 - Applicability of chapter. - 58-17H-4. Applicability of chapter. The provisions of this chapter apply...
Section 58-17H-5 - Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services. - 58-17H-5. Health carrier to provide emergency services coverage without requiring...
Section 58-17H-6 - In-network emergency services. - 58-17H-6. In-network emergency services. Coverage of in-network emergency services are...
Section 58-17H-7 - Cost-sharing requirements for out-of-network emergency services. - 58-17H-7. Cost-sharing requirements for out-of-network emergency services. Cost-sharing requirements for...
Section 58-17H-8 - Cost-sharing requirements for covered persons--Payments to out-of-network providers. - 58-17H-8. Cost-sharing requirements for covered persons--Payments to out-of-network providers. Notwithstanding...
Section 58-17H-9 - Exceptions for payments by capitated and other plans without negotiated fees. - 58-17H-9. Exceptions for payments by capitated and other plans without...
Section 58-17H-10 - Negotiated amounts for in-network providers for a particular emergency service. - 58-17H-10. Negotiated amounts for in-network providers for a particular emergency...
Section 58-17H-11 - General cost-sharing requirements allowed. - 58-17H-11. General cost-sharing requirements allowed. Any cost-sharing requirement other than...
Section 58-17H-12 - Access to representative for post-evaluation or post-stabilization services. - 58-17H-12. Access to representative for post-evaluation or post-stabilization services. For...
Section 58-17H-13 - Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body. - 58-17H-13. Health carrier may be deemed to meet emergency medical...
Section 58-17H-14 - Health carrier responsibility for utilization review activities. - 58-17H-14. Health carrier responsibility for utilization review activities. A health...
Section 58-17H-15 - Director to hold health carrier responsible for utilization review performance of contractor. - 58-17H-15. Director to hold health carrier responsible for utilization review...
Section 58-17H-16 - Written utilization review program required--Contents of program document. - 58-17H-16. Written utilization review program required--Contents of program document. A...
Section 58-17H-17 - Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request. - 58-17H-17. Utilization review program to use documented clinical review criteria--Criteria...
Section 58-17H-18 - Program to be administered by qualified licensed health care professionals. - 58-17H-18. Program to be administered by qualified licensed health care...
Section 58-17H-19 - Determinations to be issued in timely manner--Process to ensure consistency. - 58-17H-19. Determinations to be issued in timely manner--Process to ensure...
Section 58-17H-20 - Effectiveness and efficiency of program to be routinely reviewed. - 58-17H-20. Effectiveness and efficiency of program to be routinely reviewed....
Section 58-17H-21 - Data systems to support program activities and generate management reports. - 58-17H-21. Data systems to support program activities and generate management...
Section 58-17H-22 - Health carrier oversight of delegated activities--Requirements. - 58-17H-22. Health carrier oversight of delegated activities--Requirements. If a health...
Section 58-17H-23 - Utilization review to be coordinated with other medical management activity of health carrier. - 58-17H-23. Utilization review to be coordinated with other medical management...
Section 58-17H-24 - Health carrier to provide free access to review staff. - 58-17H-24. Health carrier to provide free access to review staff....
Section 58-17H-25 - Only information necessary for review or determination to be collected. - 58-17H-25. Only information necessary for review or determination to be...
Section 58-17H-26 - Independence and impartiality required for utilization review. - 58-17H-26. Independence and impartiality required for utilization review. In conducting...
Section 58-17H-27 - Written procedures required for making determinations--Notification. - 58-17H-27. Written procedures required for making determinations--Notification. A health carrier...
Section 58-17H-28 - Prospective review determinations--Timing--Notification of requirements--Extension of time. - 58-17H-28. Prospective review determinations--Timing--Notification of requirements--Extension of time. For any...
Section 58-17H-29 - Concurrent review determinations--Timing--Notification requirements. - 58-17H-29. Concurrent review determinations--Timing--Notification requirements. For concurrent review determinations, if...
Section 58-17H-30 - Retrospective review determinations--Timing--Notification requirements. - 58-17H-30. Retrospective review determinations--Timing--Notification requirements. For retrospective review determinations, the...
Section 58-17H-31 - Calculation of time period for determination for prospective and retrospective reviews. - 58-17H-31. Calculation of time period for determination for prospective and...
Section 58-17H-32 - Notification of adverse determination--Contents. - 58-17H-32. Notification of adverse determination--Contents. Any notification of an adverse...
Section 58-17H-33 - Information required to be provided to covered persons and prospective covered persons. - 58-17H-33. Information required to be provided to covered persons and...
Section 58-17H-34 - Health carrier may be deemed to meet utilization review requirements if met by private accrediting body. - 58-17H-34. Health carrier may be deemed to meet utilization review...
Section 58-17H-35 - Registration of utilization review organizations--Required information. - 58-17H-35. Registration of utilization review organizations--Required information. Any utilization review...
Section 58-17H-36 - Filing changes in registration information. - 58-17H-36. Filing changes in registration information. Any utilization review organization...
Section 58-17H-37 - Requests for information from utilization review organizations. - 58-17H-37. Requests for information from utilization review organizations. The director...
Section 58-17H-38 - Activities of nonregistered utilization review organizations prohibited. - 58-17H-38. Activities of nonregistered utilization review organizations prohibited. A utilization...
Section 58-17H-39 - Registration fee for utilization review organizations. - 58-17H-39. Registration fee for utilization review organizations. The director may...
Section 58-17H-40 - Urgent care requests--Written procedures required for receipt and determination of requests. - 58-17H-40. Urgent care requests--Written procedures required for receipt and determination...
Section 58-17H-41 - Insufficient information for determination--Notice and statement of necessary information. - 58-17H-41. Insufficient information for determination--Notice and statement of necessary information....
Section 58-17H-42 - Insufficient information for determination of prospective urgent care requests. - 58-17H-42. Insufficient information for determination of prospective urgent care requests....
Section 58-17H-43 - Urgent care requests--Timely notification of determination. - 58-17H-43. Urgent care requests--Timely notification of determination. For an urgent...
Section 58-17H-44 - Time within which to submit necessary information. - 58-17H-44. Time within which to submit necessary information. The health...
Section 58-17H-45 - Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification. - 58-17H-45. Urgent care requests--Notice of determination--Failure to submit necessary information...
Section 58-17H-46 - Concurrent review urgent care requests--Extended care requests--Time for determination and notice. - 58-17H-46. Concurrent review urgent care requests--Extended care requests--Time for determination...
Section 58-17H-47 - Calculation of time periods for determination. - 58-17H-47. Calculation of time periods for determination. For purposes of...
Section 58-17H-48 - Notification of adverse determination--Requirements. - 58-17H-48. Notification of adverse determination--Requirements. If a health carrier's determination...
Section 58-17H-49 - Promulgation of rules. - 58-17H-49. Promulgation of rules. The director may, after consultation with...
Section 58-17H-50 - Coverage for cancer treatment medication. - 58-17H-50. Coverage for cancer treatment medication. Any health benefit plan...
Section 58-17H-51 - Reclassification of benefits with respect to cancer treatment medications. - 58-17H-51. Reclassification of benefits with respect to cancer treatment medications....
Section 58-17H-52 - Medical management practices complying with chapter. - 58-17H-52. Medical management practices complying with chapter. Nothing in §§58-17H-50...
Section 58-17H-53 - Step therapy protocols. - 58-17H-53 . Step therapy protocols. A health carrier, health benefit...
Section 58-17H-54 - Step therapy protocols--Process--Transparency. - 58-17H-54 . Step therapy protocols--Process--Transparency. When coverage of a prescription...
Section 58-17H-55 - Step therapy override exceptions. - 58-17H-55 . Step therapy override exceptions. A step therapy override...
Section 58-17H-56 - Limitations. - 58-17H-56 . Limitations. Nothing in §§ 58-17H-53 to 55-17H-56 shall...