§ 36-6553. Private review agents - Certification required - Exemptions.

A.  A private review agent who approves or denies payment or who recommends approval or denial of payment for hospital or medical services or whose review results in approval or denial of payment for hospital or medical services on a case-by-case basis shall not conduct utilization review in this state unless the Insurance Commissioner has granted the private review agent a certificate.

B.  Except as provided in Section 9 of this act, the Hospital and Medical Services Utilization Review Act shall not apply to any insurance company or not-for-profit hospital service and medical indemnity plan licensed by the Commissioner to transact insurance in this state.  If the insurer contracts outside the company for any or all utilization review services, the entity with whom the insurance company contracts shall be subject to all of the provisions of the Hospital and Medical Services Utilization Review Act.

C.  The State and Education Employees Group Insurance Board shall be exempt from the provisions of the Hospital and Medical Services Utilization Review Act and regulated accordingly as provided for in the State and Education Employees Group Insurance Act.  In addition, the Board shall comply with the provisions of Section 17 of this act.  If the State and Education Employees Group Insurance Board contracts for utilization review services instead of having utilization review services be performed by employees of the Board, the entity with whom the Board contracts shall be subject to all of the provisions of the Hospital and Medical Services Utilization Review Act.

Added by Laws 1991, c. 294, § 3, eff. Nov. 1, 1991.