Missouri Revised Statutes
Chapter 376
Life, Health and Accident Insurance
←376.1359
Section 376.1361.1
376.1363→
August 28, 2015
Documented clinical review criteria used in a utilization program--medical director qualifications--compensation of utilization review services.
376.1361. 1. A utilization review program shall use documented clinical
review criteria that are based on sound clinical evidence and are evaluated
periodically to assure ongoing efficacy. A health carrier may develop its
own clinical review criteria, or it may purchase or license clinical review
criteria from qualified vendors. A health carrier shall make available its
clinical review criteria upon request by either the director of the
department of health and senior services or the director of the department of
insurance, financial institutions and professional registration.
2. Any medical director who administers the utilization review program
or oversees the review decisions shall be a qualified health care
professional licensed in the state of Missouri. A licensed clinical peer
shall evaluate the clinical appropriateness of adverse determinations.
3. A health carrier shall issue utilization review decisions in a timely
manner pursuant to the requirements of sections 376.1363, 376.1365 and
376.1367. A health carrier shall obtain all information required to make a
utilization review decision, including pertinent clinical information. A
health carrier shall have a process to ensure that utilization reviewers
apply clinical review criteria consistently.
4. A health carrier's data systems shall be sufficient to support
utilization review program activities and to generate management reports to
enable the health carrier to monitor and manage health care services
effectively.
5. If a health carrier delegates any utilization review activities to a
utilization review organization, the health carrier shall maintain adequate
oversight, which shall include:
(1) A written description of the utilization review organization's
activities and responsibilities, including reporting requirements;
(2) Evidence of formal approval of the utilization review organization
program by the health carrier; and
(3) A process by which the health carrier evaluates the performance of
the utilization review organization.
6. The health carrier shall coordinate the utilization review program
with other medical management activities conducted by the carrier, such as
quality assurance, credentialing, provider contracting, data reporting,
grievance procedures, processes for accessing member satisfaction and risk
management.
7. A health carrier shall provide enrollees and participating providers
with timely access to its review staff by a toll-free number.
8. When conducting utilization review, the health carrier shall collect
only the information necessary to certify the admission, procedure or
treatment, length of stay, frequency and duration of services.
9. Compensation to persons providing utilization review services for a
health carrier shall not contain direct or indirect incentives for such
persons to make medically inappropriate review decisions. Compensation to
any such persons may not be directly or indirectly based on the quantity or
type of adverse determinations rendered.
10. A health carrier shall permit enrollees or a provider on behalf of an
enrollee to appeal for the coverage of medically necessary pharmaceutical
prescriptions and durable medical equipment as part of the health carriers'
utilization review process.
11. (1) This subsection shall apply to:
(a) Any health benefit plan that is issued, amended, delivered or renewed
on or after January 1, 1998, and provides coverage for drugs; or
(b) Any person making a determination regarding payment or reimbursement
for a prescription drug pursuant to such plan.
(2) A health benefit plan that provides coverage for drugs shall provide
coverage for any drug prescribed to treat an indication so long as the drug
has been approved by the FDA for at least one indication, if the drug is
recognized for treatment of the covered indication in one of the standard
reference compendia or in substantially accepted peer-reviewed medical
literature and deemed medically appropriate.
(3) This section shall not be construed to require coverage for a drug
when the FDA has determined its use to be contraindicated for treatment of
the current indication.
(4) A drug use that is covered pursuant to subsection 1 of this section
shall not be denied coverage based on a "medical necessity" requirement
except for a reason that is unrelated to the legal status of the drug use.
(5) Any drug or service furnished in a research trial, if the sponsor of
the research trial furnishes such drug or service without charge to any
participant in the research trial, shall not be subject to coverage pursuant
to subsection 1 of this section.
(6) Nothing in this section shall require payment for nonformulary drugs,
except that the state may exclude or otherwise restrict coverage of a covered
outpatient drug from Medicaid programs as specified in the Social Security
Act, Section 1927(d)(1)(B).
12. A carrier shall issue a confirmation number to an enrollee when the
health carrier, acting through a participating provider or other authorized
representative, authorizes the provision of health care services.
13. If an authorized representative of a health carrier authorizes the
provision of health care services, the health carrier shall not subsequently
retract its authorization after the health care services have been provided,
or reduce payment for an item or service furnished in reliance on approval,
unless
(1) Such authorization is based on a material misrepresentation or
omission about the treated person's health condition or the cause of the
health condition; or
(2) The health benefit plan terminates before the health care services
are provided; or
(3) The covered person's coverage under the health benefit plan
terminates before the health care services are provided.
(L. 1997 H.B. 335)
Top
Missouri General Assembly
Copyright © Missouri Legislature, all rights reserved.
