Utilization Review Company Minimum Standards

CONNECTICUT WORKERS' COMPENSATION COMMISSION Utilization Review Company minimum standards for compliance with C.G.S. §31-279 and Administrative Regulations §31-279-10 Medical Care Plan: ______________________________________________________________ Address: Telephone: ________________________ Toll Free: ___________________________ Business Hours (eastern time): _____________________________________________ Contact Person: _________________________________________________________ Direct Telephone #: ______________________________________________________ Email address: __________________________________________________________ Utilization Review Company: ___________________________________________________ Address: American LegalNet, Inc. www.FormsWorkFlow.com 1. Please indicate compliance with the following standards pursuant to Connecticut General Statutes §31-279 and administrative regulations §31-279-10: o Not more than two (2) business days after receipt of all information regarding request for authorization of treatment, written notice shall be provided to the provider and employee of its determination regarding the recommended treatment. o In the case of an emergency condition, an employee or his representative shall be provided a minimum of twenty-four (24) hours following an admission, service or procedure to request certification and continuing treatment for that emergency condition before a utilization determination is made. If a determination is made not to provide such continuing treatment and the employee or his representative, the provider, or the employer requests a review of such determination, an expedited review shall be conducted by the medical director and a final decision rendered within two (2) days of the request for review. o Any written notice of a determination not to certify an admission, service, procedure or extension of stay shall include the reasons and the name and telephone number of the person to contact with regard to an appeal. The provider and the employee shall also be provided with a copy of the written review and appeal procedures. o The provider or the employee may, within fifteen (15) days of the written notice of determination, notify the plan of his or her intent to appeal a determination to deny payment for the recommended treatment. o Upon such appeal, at the request of the employee or provider, a practitioner in a specialty relating to the employee's condition for the purpose of reviewing the initial decision shall be provided o Within fifteen (15) days of the request for such review and submission of any further documentation regarding the review, the reviewing practitioner shall submit his opinion regarding such recommended treatment to the medical director of the medical care plan who shall, within fifteen (15) days thereafter, render a written decision regarding such treatment. o The employee, the provider or the employer may request a further review of the medical director's written decision; such request for further review shall be in writing and shall be submitted to the chief executive officer of the medical care plan within fifteen (15) days of the medical director's written decision. The party requesting further review shall have an opportunity for a hearing if such party requests it in writing and may, at such party's expense, produce whatever written support or oral testimony it wishes at any such hearing. Such hearing shall be conducted within fifteen (15) days of the written request. The chief executive officer of the medical care plan shall make any final determination of such request for further review and may utilize an advisory committee to assist him in his determination. o o o o The chief executive officer shall issue a final written decision on the request for further review as soon as practical but, in any event, within thirty (30) days of the later of the date of submission of the written request for such review or the date of conclusion of the hearing requested as part of such review. o The utilization review and appeal procedures personnel shall, at a minimum, satisfy the following standards: x Nurses and other health professionals other than physicians making utilization review recommendations and decisions shall hold current and valid licenses from a state licensing agency in the United States. Physicians making utilization review recommendations and decisions shall hold current and valid licenses in the State of Connecticut. American LegalNet, Inc. www.FormsWorkFlow.com x x Utilization review staff shall be generally available by toll-free telephone, at least forty hours per week during regular business hours. Each utilization review professional shall comply with all applicable state and federal laws to protect the confidentiality of individual medical records; summary and aggregate data shall not be considered confidential if it does not provide sufficient information to allow identification of individual patients. Each utilization review professional shall conduct its telephone and on-site information gathering reviews and hospital communications during the hospitals' reasonable and normal business hours, unless otherwise mutually agreed. Utilization review professionals shall identify themselves by name and by the name of their organization, if any, and, for on-site reviews, shall carry picture identification. x x No utilization review professional may receive any financial incentive based on the number of denials of certification made by such professional. 2. Indicate how the UR company is reimbursed for services: 3. Describe the professional liability coverage maintained by the UR company with respect to legal liability: 4. Indicate how reviewers are compensated: American LegalNet, Inc. www.FormsWorkFlow.com 5. Is the UR company currently accredited by URAC? 6. List all states where the company is currently licensed to perform UR: 7. Have any sanctions, fines, revocation, or restriction of licensure been imposed on the UR company by any regulatory agency? If yes, please explain: American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION STATEMENT The undersigned, being duly sworn, hereby certifies on behalf of _________________________ _____________________________________________________________________________ (company) that the information provided herein is true and accurate, and further swears that by virtue of my position as __________________________________________________ , I am vested