Bill Text: AZ HB2490 | 2013 | Fifty-first Legislature 1st Regular | Chaptered
Bill Title: Utilization review; requirements.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Passed) 2013-04-05 - Governor Signed [HB2490 Detail]
Download: Arizona-2013-HB2490-Chaptered.html
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Senate Engrossed House Bill |
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State of Arizona House of Representatives Fifty-first Legislature First Regular Session 2013
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CHAPTER 60
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HOUSE BILL 2490 |
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AN ACT
Amending sections 20‑2508 and 20‑2510, Arizona Revised Statutes; relating to utilization review.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Section 20-2508, Arizona Revised Statutes, is amended to read:
20-2508. Denial, suspension or revocation of certificates; hearing; civil penalties
A. The director shall deny a certificate if the director finds that the utilization review agent does not:
1. Have an allopathic or osteopathic physician available to supervise utilization review activities of any medical, surgical or health care services except that:
(a) A dental service corporation that is licensed pursuant to chapter 4, article 3 of this title and a prepaid dental plan organization that is licensed pursuant to chapter 4, article 7 of this title may have a licensed dentist supervise or conduct utilization review activities for health care services that involve dental care.
(b) An optometric service corporation that is licensed pursuant to chapter 4, article 3 of this title may have a licensed optometrist supervise or conduct utilization review activities for health care services that involve optometric care.
(c) A utilization review agent shall have a licensed chiropractor supervise or conduct utilization review activities for health care services that are performed by a chiropractor and within the chiropractor's scope of practice pursuant to title 32, chapter 8.
2. Meet all applicable department rules relating to the qualifications of utilization review agents or the performance of utilization review.
3. Provide assurances satisfactory to the director that the procedure and policies of the utilization review agent will protect the confidentiality of medical records and the utilization review agent will be reasonably accessible to patients and providers in this state and the department by a toll free telephone line or by acceptance of long‑distance collect calls for forty hours each week during normal business hours.
B. The director shall deny a certificate to a utilization review agent who has been convicted of a misdemeanor involving moral turpitude or a felony or who employs a person who has been convicted of a felony.
C. The director may suspend, revoke or refuse to renew a certificate issued under this chapter if after giving notice to the utilization review agent, and holding a hearing if demanded by the agent, the director finds that the agent has violated this chapter or a rule adopted under this chapter.
D. If after a hearing the director finds that the agent has violated this chapter or an applicable rule or order adopted under this chapter, the director shall issue an order that specifies the violation and may impose a civil penalty of not more than two hundred fifty dollars for each violation or an aggregate civil penalty of not more than two thousand five hundred dollars. The director may also impose a civil penalty of not more than two thousand five hundred dollars for each knowing violation or an aggregate civil penalty of not more than fifteen thousand dollars. The director shall deposit, pursuant to sections 35‑146 and 35‑147, all monies in the state general fund. A civil penalty is in addition to any other applicable penalty or restraint provided in this chapter and may be recovered in a civil action brought by the director.
E. A certificate does not expire or terminate until a pending department investigation is resolved but is suspended on the date it would otherwise expire or terminate. The utilization review agent shall not transact business in this state until the investigation is completed.
F. When the director suspends or revokes a certificate the director shall immediately notify the utilization review agent either by personal service or by mail addressed to the agent at the agent's address of record. Notice by mail is effective at the time it is mailed.
G. The utilization review agent shall deliver a revoked or suspended certificate to the director on the director's request.
H. The director shall not issue a new certificate earlier than one year after the date of a previous revocation. Agents shall reapply to the director and shall meet all the requirements of this chapter to obtain a new certificate.
I. If the certificate of a firm or corporation is suspended or revoked, no member of that firm or officer or director of the corporation may hold a certificate during the period of the suspension or revocation unless the director determines, based on substantial evidence, that the member, officer or corporation director was not personally at fault.
Sec. 2. Section 20-2510, Arizona Revised Statutes, is amended to read:
20-2510. Health care insurers requirements; medical directors
A. A health care insurer that proposes to provide coverage of inpatient hospital and medical benefits, outpatient surgical benefits or any medical, surgical or health care service for residents of this state with utilization review of those benefits shall meet at least one of the following requirements:
1. Have a certificate issued pursuant to this chapter.
2. Be accredited by the utilization review accreditation commission, the national committee for quality assurance or any other nationally recognized accreditation process recognized by the director.
3. Contract with a utilization review agent that has a certificate issued pursuant to this chapter.
4. Contract with a utilization review agent that is accredited by the utilization review accreditation commission, the national committee for quality assurance or any other nationally recognized accreditation process recognized by the director.
5. Provide to the director a signed and notarized statement that the health care insurer has submitted an application for accreditation to the utilization review accreditation commission or the national committee for quality assurance and is awaiting completion of the accreditation review process. On completion of the accreditation review process, the insurer shall provide to the director adequate proof that the insurer has been accredited. If the insurer is denied accreditation, within sixty days after the denial the insurer shall meet at least one of the requirements set forth in paragraph 1, 2, 3 or 4 of this subsection.
B. Except as provided in subsections C, D and E of this section, any direct denial of prior authorization of a service requested by a health care provider on the basis of medical necessity by a health care insurer shall be made in writing by a medical director who holds an active unrestricted license to practice medicine in this state pursuant to title 32, chapter 13 or 17. The written denial shall include an explanation of why the treatment was denied, and the medical director who made the denial shall sign the written denial. The health care insurer shall send a copy of the written denial to the health care provider who requested the treatment. Health care insurers shall maintain copies of all written denials and shall make the copies available to the department for inspection during regular business hours. The medical director is responsible for all direct denials that are made on the basis of medical necessity. Nothing in this section prohibits a health care insurer from consulting with a licensed physician whose scope of practice may provide the health care insurer with a more thorough review of the medical necessity.
C. For determinations made pursuant to subsection B of this section, a dental service corporation as defined in section 20‑822 or a prepaid dental plan organization as defined in section 20‑1001 may use as a medical director either:
1. An individual who holds an active unrestricted license to practice dentistry in this state pursuant to title 32, chapter 11.
2. A physician who holds an active unrestricted license to practice medicine in this state pursuant to title 32, chapter 13 or 17.
D. For determinations made pursuant to subsection B of this section, an optometric service corporation may use as a medical director either:
1. An individual who holds an active unrestricted license to practice optometry in this state pursuant to title 32, chapter 16.
2. A physician who holds an active unrestricted license to practice medicine in this state pursuant to title 32, chapter 13 or 17.
E. For determinations made pursuant to subsection B of this section, a health care insurer may shall use a chiropractor licensed in this state pursuant to title 32, chapter 8 or by any regulatory board in another state to review any direct denial of prior authorization of a chiropractic service requested by a chiropractor on the basis of medical necessity.
APPROVED BY THE GOVERNOR APRIL 5, 2013.
FILED IN THE OFFICE OF THE SECRETARY OF STATE APRIL 5, 2013.
