TITLE XXXVII
INSURANCE
Chapter 420-E
LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES
Section 420-E:1
420-E:1 Definitions. –
In this chapter:
I. "Commissioner" means the insurance commissioner.
I-a. "Claim involving urgent care" means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations:
(a) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
(b) In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
I-b. "Clinical review criteria" means the written policies, screening procedures, decision abstracts, clinical or medical protocols, practice guidelines, and any other written decision-making standards used by a utilization review entity to determine the medical necessity and appropriateness of health care services.
II. "Department" means the insurance department.
III. "Health care provider" means any person, corporation, facility, or institution either licensed by this state or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital or other health care facility, dentist, nurse, optometrist, podiatrist, physical therapist or psychologist, and any officer, employee or agent of such provider acting in the course and scope of his employment or agency related to or supportive of health care services.
III-a. [Deleted.]
IV. "Medical necessity" means health care services or products provided to an enrollee for the purpose of preventing, stabilizing, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease in a manner that is:
(a) Consistent with generally accepted standards of medical practice;
(b) Clinically appropriate in terms of type, frequency, extent, site, and duration;
(c) Demonstrated through scientific evidence to be effective in improving health outcomes;
(d) Representative of "best practices" in the medical profession; and
(e) Not primarily for the convenience of the enrollee or physician or other health care provider.
V. "Pre-service claim" means a request for prior authorization.
VI. "Prior authorization" means the approval from a health carrier or utilization review entity that may be required before a particular health care service, item, or prescription drug is received by the covered person in order for that service, item, or prescription drug to be covered under the covered person's plan.
VII. "Prior authorization determination" means a determination by a health carrier or utilization review entity that a health care service, item or prescription drug has been reviewed pursuant to a pre-service request for prior authorization and, based on the information provided, satisfies or does not satisfy the health carrier's or utilization review entity's requirements for coverage.
VIII. "Utilization review" means a set of formal techniques designed to monitor the use of or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services procedures, providers, or facilities, for the purpose of recommending or determining whether such services should be covered or provided by an insurer, nonprofit service organization, health maintenance organization, third-party administrator, or employer. Techniques and methods may include, but are not limited to, ambulatory care review, case management, concurrent hospital review, discharge planning, pre-hospital admission certification, pre-inpatient service eligibility certification, prospective review, prior authorization, second opinion, or retrospective review.
Source. 1992, 142:2. 1996, 188:12. 2001, 207:4, 5, eff. Jan. 1, 2002. 2024, 172:8, 9, eff. Jan. 1, 2025.
Section 420-E:2
420-E:2 Licensure or Registration Required. –
I. Any person, partnership or corporation, other than an insurer, nonprofit service organization, health maintenance organization, or an employee of those exempt organizations, that performs medical utilization review services on behalf of commercial insurers, nonprofit service organizations, health maintenance organizations, third-party administrators or employers, shall apply for a license to be issued by the department and shall pay an application fee and an annual license fee. No person, partnership or corporation, other than an insurer, nonprofit service organization, health maintenance organization, or the employees of exempt organizations shall perform utilization review services or medical utilization review services unless the person, partnership, or corporation has received a license in accordance with this chapter.
II. [Repealed.]
Source. 1992, 142:2. 1993, 249:1. 1996, 188:13. 1997, 345:8, III. 1999, 249:4, eff. Sept. 7, 1999.
Section 420-E:2-a
420-E:2-a Medical Director. –
Every medical utilization review entity licensed by the department under this chapter shall employ one or more medical directors licensed under RSA 329 or, in the case of a dental utilization review entity, a dentist licensed under RSA 317-A.
Source. 2000, 18:3. 2004, 187:5, eff. July 31, 2004. 2024, 172:10, eff. Jan. 1, 2025.
Section 420-E:3
420-E:3 Information Required. –
I. Each person, partnership or corporation licensed under this chapter shall, at the time of initial licensure and on or before April 1 of each succeeding year, provide the department with the following information:
(a) The process used by the entity to carry out its utilization review services, including the categories of health care personnel that perform utilization review activities and whether or not such individuals are licensed in this state.
(b) The process used by the entity for addressing beneficiary or provider complaints.
(c) The types of utilization review programs offered by the entity, including, but not limited to:
(1) Second opinion programs.
(2) Prehospital admission certification.
(3) Preinpatient service eligibility determination.
(4) Concurrent hospital review to determine appropriate length of stay.
(d) The process used by the entity to preserve beneficiary confidentiality of medical information.
II. Each person, partnership, or corporation licensed under this chapter shall adopt as the minimal acceptable standards for licensure either the Utilization Review Accreditation Commission (URAC) standards, the National Committee for Quality Assurance (NCQA) standards, or other similar standards acceptable to the commissioner, unless rules establishing stricter standards are adopted pursuant to the commissioner's authority under RSA 420-E:7, XII.
Source. 1992, 142:2. 1993, 249:2. 1999, 249:5, eff. Sept. 7, 1999.
Section 420-E:4
420-E:4 Minimum Standards; Licensure of Medical Utilization Review Entities. –
All licensees shall establish and maintain a utilization review procedure by which a claimant or claimant's representative may seek a claim benefit determination. The procedure shall meet the following minimum standards:
I. The licensee shall maintain a toll-free telephone number to ensure that a representative of the licensee shall be accessible by telephone to insureds, patients, and providers 7 days a week during normal working hours.
II. Claim benefit determinations shall be made by a licensed or certified health care provider.
III. Clinical review criteria considered or utilized in making claim benefit determinations shall be:
(a) Developed with input from appropriate actively practicing practitioners in the carrier or other licensed entity's service area;
(b) Updated at least biennially and as new treatments, applications, and technologies emerge;
(c) Developed in accordance with the standards of national accreditation entities:
(d) Based on current, nationally accepted standards of medical practice; and
(e) If practicable, evidence-based.
IV. Notification of claim benefit determinations shall be made within the following time periods:
(a) The determination of a claim involving urgent care shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 72 hours after receipt of the claim, unless the claimant or claimant's representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable. In the case of such failure, the licensee shall notify the claimant or claimant's representative within 24 hours of receipt of the claim and shall advise the claimant or claimant's representative of the specific information necessary to determine the claim. The claimant or claimant's representative shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. Thereafter, notification of the benefit determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.
(b) The determination of a claim involving urgent care and relating to the extension of an ongoing course of treatment and involving a question of medical necessity shall be made within 24 hours of receipt of the claim; provided, that the claim is made at least 24 hours prior to the expiration of the prescribed period of time or course of treatment.
(c) The determination of all other claims for preservice benefits shall be made within a reasonable time period appropriate to the medical circumstances, but in no event more than 15 days after receipt of the claim. This period may be extended one time by the licensee for up to 15 days; provided, that the licensee both determines that such an extension is necessary due to matters beyond the control of the licensee and notifies the claimant or claimant's representative, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which the licensee expects to render a decision. If such an extension is necessary due to a failure of the claimant or claimant's representative to provide sufficient information to determine whether, or to what extent, benefits are covered as payable, the notice of extension shall specifically describe the required additional information needed, and the claimant or claimant's representative shall be given at least 45 days from receipt of the notice within which to provide the specified information. Notification of the benefit determination following a request for additional information shall be made as soon as possible, but in no case later than 15 days after the earlier of (1) the licensee's receipt of the specified additional information, or (2) the end of the period afforded the claimant or claimant's representative to provide the specified additional information.
(d) The determination of a post service claim shall be made within 30 days of the date of filing. In the event the claimant fails to provide sufficient information to determine the claim, the carrier shall notify the claimant within 15 days as to what additional information is required to process the claim and the claimant shall be given at least 45 days to provide the required information. The 30-day period for claim determination shall be tolled until such time as the claimant submits the required information.
V. The manner and content of notification of claim benefit determinations shall be as follows:
(a) The licensee shall notify the claimant or claimant's representative in writing or electronically of the claim determination.
(b) If the claim benefit determination is a claim denial, the notice shall include:
(1) The specific reason or reasons for the determination and shall refer to the specific provision of the policy or plan on which the determination is based.
(2) A statement of the claimant's right or the right of the claimant's representative to access the internal grievance process and the process for obtaining external review.
(3) If the claim denial is based upon a determination that the claim is experimental or investigational or not medically necessary or appropriate:
(A) The name and credentials of the carrier or other licensed entity, the medical director, including board status and the state or states where the person is currently licensed. If the person making the claim denial is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person; and
(B) An explanation of the clinical rationale for the determination. This explanation shall recite the terms of the plan or the policy or of any clinical review criteria or any internal rule, guideline, protocol, or other similar provision that was relied upon in making the claim denial and how these provisions apply to the claimant's specific medical circumstances;
(4) If an internal rule, guideline, protocol, or other similar provision was relied upon in making the benefit determination, a statement that such rule, guideline, protocol, or other similar provision was relied upon in making the claim denial;
(5) If clinical review criteria were relied upon in making the benefit determination, a statement that such clinical review criteria were relied upon in making the claim denial. The recitation of terms of the clinical review criteria required under RSA 420-E:4, V(b)(3)(B) shall be accompanied by the following notice: "The clinical review criteria provided to you are used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract;"
(6) In the case of a denial of a benefit concerning a claim involving urgent care or in the case of a denial of a claim related to continuation of an ongoing course of treatment for a person who has received emergency services, but who has not been discharged from a facility, a description of the expedited review applicable to such a claim shall be included in the determination. For all other claim benefit determinations, a description of the grievance process shall be specifically described in the determination.
VI. A licensee shall file with the department a copy of the materials designed to inform patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan and an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed.
VII. In any request for a benefit determination, the claimant may authorize a representative to pursue the claim or benefit determination by submitting a written statement to the licensee that acknowledges the representation.
VIII. No fees or costs shall be assessed against a claimant related to a request for claim benefit determination.
Source. 1992, 142:2. 1993, 249:3. 1996, 270:1. 2000, 18:16. 2001, 207:6. 2003, 276:8-10. 2006, 304:4, eff. Aug. 18, 2006.
Section 420-E:4-a
420-E:4-a Uniform Prior Authorization Forms and Electronic Standard for Prescription Drug Benefits. –
I. Beginning July 1, 2017, all health insurers, health maintenance organizations, health services corporations, medical services corporations, and preferred provider programs may, when requiring prior authorization for a prescription drug, use and accept the prior authorization paper forms or electronic standard described in this section.
II. Beginning December 31, 2017, all health insurers, health maintenance organizations, health services corporations, medical services corporations, and preferred provider programs shall, when requiring prior authorization for a prescription drug, use and accept only the prior authorization paper forms or electronic standard described in this section.
III. On or before March 1, 2017, the commissioner shall adopt rules, pursuant to RSA 541-A, specifying the contents and format of the uniform prior authorization paper forms and the electronic prior authorization standard, consistent with the requirements of this section. In developing the paper forms and the electronic standard, the commissioner shall seek input from interested stakeholders, including but not limited to prescribers, pharmacists, carriers, and prescription benefits managers, and shall support adoption of nationally recognized standards for electronic prior authorization of prescription drugs, including those provided by the National Council for Prescription Drug Programs or an equivalent organization as available.
IV. The prior authorization paper forms adopted under this section shall not exceed 2 pages in length.
V. Nothing in this section shall require a carrier or pharmacy benefits manager to use electronic prior authorization. A carrier or pharmacy benefits manager shall not require use of electronic prior authorization when:
(a) A pharmacist or prescriber lacks broadband Internet access;
(b) A pharmacist or prescriber has low patient volume;
(c) A pharmacist or prescriber has opted-out for a certain medical condition or for a patient request;
(d) A pharmacist or prescriber lacks an electronic medical record system;
(e) The electronic prior authorization interface does not provide for the pre-population of prescriber and patient information; or
(f) The electronic prior authorization interface requires an additional cost to the prescriber.
VI. Nothing in this section shall prohibit the use of prior authorization for prescription drug benefits.
VII. This section shall apply to RSA 420-J and shall not apply to the Medicaid managed care program under RSA 126-A:5, XIX.
Source. 2016, 228:3, eff. June 9, 2016.
Section 420-E:4-b
420-E:4-b Prior Authorization Standards for Managed Care Plans. –
The following prior authorization requirements apply to utilization review entities conducting prior authorization review determinations for managed care plans operating subject to RSA 420-J.
I. Timeliness standards for processing prior authorization requests submitted electronically. Utilization review entities administering fully insured coverage for managed care plans subject to RSA 420-J shall meet the following time frames for prior authorization determinations requested by participating providers or facilities that submit the prior authorization request through an electronic prior authorization process as designated by the utilization review entity:
(a) In non-urgent circumstances, utilization review entities requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination within 7 calendar days of obtaining all information necessary to make the determination. Any request that the utilization review entity makes for additional information necessary to make the determination shall be made within 7 calendar days of the prior authorization request date.
(b) In urgent circumstances, utilization review entities requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination as expeditiously as the covered person's medical condition requires, and not later than 72 hours after obtaining all information necessary to make the determination. Any request that the utilization review entity makes for additional information necessary to make the determination shall be made as expeditiously as required to meet the 72-hour timeline, assuming a timely response from the treating provider.
II. Timeliness standards for processing prior authorization requests submitted non-electronically. Utilization review entities shall meet the following time frames for prior authorization determinations requested by participating providers or facilities that submit the prior authorization request through a non-electronic prior authorization process as designated by the utilization review entity:
(a) In non-urgent circumstances, utilization review entities requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination within 14 calendar days of obtaining all information necessary to make the determination. Any request that the utilization review entity makes for additional information necessary to make the determination shall be made within 7 calendar days of the prior authorization request date.
(b) In urgent circumstances, utilization review entities requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination as expeditiously as the covered person's medical condition requires, and not later than 72 hours after obtaining all information necessary to make the determination. Any request that the utilization review entity makes for additional information necessary to make the determination shall be made as expeditiously as required to meet the 72-hour timeline, assuming a timely response from the treating provider.
III. In paragraphs I and II, "all information necessary to make the determination" shall include the information provided through a peer-to-peer review.
IV. A prior authorization request shall be considered approved if the utilization review entity fails to notify the covered person and the covered person's health care provider of the prior authorization determination within the timeliness standards for making a determination after obtaining all necessary information.
V. Duration of an approval of a prior authorization request. Utilization review entities shall not revoke, limit, condition, or restrict a prior authorization if care is provided within 60 business days from the date the health care provider received approval of the prior authorization request.
VI. A utilization review entity conducting utilization review directly, or indirectly through a contracted utilization review entity, shall pay a participating health care provider at the contracted payment rate for a health care service provided by the health care provider pursuant to a prior authorization determination that coverage is available unless:
(a) The health care provider materially misrepresented the health care service in the prior authorization request;
(b) The health care service was no longer a covered benefit on the day it was provided;
(c) The health care provider was no longer contracted with the covered person's utilization review entity on the date the care was provided;
(d) The health care provider failed to meet the utilization review entity's timely filing requirements;
(e) The patient was no longer eligible for health care coverage on the day the care was provided; or
(f) The utilization review entity does not have liability for the claim or for a part of the claim for any reason under the covered person's coverage policy, the provider contract between the utilization review entity and the participating provider, or any other reason applicable at law or in equity.
VII. Option to request a peer-to-peer review. When a utilization review entity requires prior authorization for an item or service, the utilization review entity shall offer the provider the opportunity to request a peer-to-peer review of a prior authorization request in which the provider is able to have a direct conversational exchange with a medical director or a designated provider who is a clinical peer about the basis for the prior authorization request. A "clinical peer" in this context shall be a health care professional who has demonstrable expertise to review a case, whether or not the reviewing professional is in the same or a similar specialty as the provider. The peer-to-peer review may be requested before the utilization review entity's prior authorization determination or after a prior authorization denial and before a formal grievance request has been made. The peer-to-peer review shall be made available by the utilization review entity within 2 business days of the request. If the peer-to-peer review is requested after a prior authorization denial, the utilization review entity shall treat the review request as a request for reconsideration that is external to the grievance process and shall provide the provider and the covered person a written determination containing a statement of the specific reasons for the reconsideration determination with reference to the information provided in the peer-to-peer review. The written reconsideration determination shall be provided within 7 business days of the peer-to-peer review.
VIII. Nothing in this section shall be construed to contravene a covered person's right to external review under RSA 420-J:5-a. Unless otherwise required by law, the prior authorization requirements set out in this chapter shall apply to all medical services and items.
Source. 2024, 172:11, eff. Jan. 1, 2025.
Section 420-E:5
420-E:5 Listing. –
The commissioner shall compile and maintain a current listing of persons, partnerships or corporations licensed pursuant to this chapter. The list shall be available to the public.
Source. 1992, 142:2, eff. July 5, 1992.
Section 420-E:6
420-E:6 Periodic Reviews. –
The commissioner or designee may conduct periodic reviews of the operations of the entities licensed under this chapter to ensure that they continue to meet the minimum standards set in RSA 420-E:4 and any applicable rules adopted by the commissioner. The commissioner may perform periodic telephone audits of licensees to determine if representatives of the licensee are reasonably accessible, as required in RSA 420-E:4, I.
Source. 1992, 142:2. 2001, 207:7, eff. Jan. 1, 2002.
Section 420-E:7
420-E:7 Rulemaking. –
The commissioner shall adopt rules, under RSA 541-A and after public hearing, relative to:
I. Procedures for application for license under RSA 420-E:2.
II. Initial application fees and annual license fees.
III. The time period for notification of determination as required under RSA 420-E:4, IV.
IV. Standards for telephone accessibility as required under RSA 420-E:4, I.
V. Manner for filing and other information for minimum standards as required under RSA 420-E:4.
VI. Manner and content of all forms required under this chapter.
VII. What shall constitute cause to take actions under RSA 420-E:6 and RSA 420-E:8.
VIII. Confidentiality of records and access to records of the provider and reviewer, as required under RSA 420-E:4.
IX. The scope of the review and the information which the reviewer is entitled to review and have access to from the provider.
X. Qualification of the reviewer, as required under RSA 420-E:4, II.
XI. Procedures for registration.
XII. Additional standards for licensure of medical utilization review entities under RSA 420-E:3, II.
Source. 1992, 142:2. 1993, 249:4. 2001, 207:8, 9. 2012, 171:24, eff. Aug. 10, 2012.
Section 420-E:8
420-E:8 Enforcement; Administrative Fine; Hearings. –
I. The commissioner may take appropriate action against a licensee which fails to meet the standards under this chapter or any rules adopted by the commissioner, or who fails to respond in a timely manner to corrective actions ordered by the commissioner. The commissioner may impose an administrative fine not to exceed $1,000 for each violation or may deny, suspend or revoke the license.
II. Before taking the actions authorized by this section to deny, suspend or revoke the license, the commissioner shall provide the licensee with reasonable time to supply additional information demonstrating compliance with the requirements of this chapter and the opportunity to request a hearing under RSA 541-A. Rehearings and appeals shall be conducted in accordance with RSA 541.
Source. 1992, 142:2, eff. July 5, 1992.
Section 420-E:9
420-E:9 Rulings on Appropriateness of Medical Judgments Not Authorized. –
Nothing in this chapter requires or authorizes the commissioner to rule on the appropriateness of medical decisions or judgments rendered by review entities and their agents.
Source. 1992, 142:2, eff. July 5, 1992.