§ 4905. Required and prohibited practices. (a) Each utilization review\nagent shall have written procedures for assuring that patient-specific\ninformation obtained during the process of utilization review will be:\n (1) kept confidential in accordance with applicable state and federal\nlaws; and\n (2) shared only with the insured, the insured's designee, the\ninsured's health care provider and those who are authorized by law to\nreceive such information.\n (b) Summary data shall not be considered confidential if it does not\nprovide information to allow identification of individual patients.\n (c) Any health care professional who makes determinations regarding\nthe medical necessity of health care services during the course of\nutilization review shall be appropriately licensed, registered or\ncertified.\n (d) A utilization review agent shall not, with respect to utilization\nreview activities, permit or provide compensation or anything of value\nto its employees, agents, or contractors based on:\n (1) either a percentage of the amount by which a claim is reduced for\npayment or the number of claims or the cost of services for which the\nperson has denied authorization or payment; or\n (2) any other method that encourages the rendering of an adverse\ndetermination.\n (e) If a health care service has been specifically preauthorized or\napproved for an insured by a utilization review agent, a utilization\nreview agent shall not pursuant to retrospective review revise or modify\nthe specific standards, criteria or procedures used for the utilization\nreview for procedures, treatment and services delivered to the insured,\nduring the same course of treatment.\n * (f) Utilization review shall not be conducted more frequently than\nis reasonably required to assess whether the health care services under\nreview are medically necessary.\n * NB Effective until January 1, 2027\n * (f) Utilization review shall not be conducted more frequently than\nis reasonably required to assess whether the health care services under\nreview are medically necessary provided, however, that utilization\nreview shall not be conducted more than once per year for an outpatient\ncourse of treatment for a chronic health condition starting from the\ndate of a pre-authorization approval for the course of treatment unless\nthe insured's attending provider recommends a change to the course of\ntreatment, then utilization review may be conducted for the new course\nof treatment. Any new treatment, testing or procedures related to the\nspecific medical problem, condition, or illness being managed but not\nalready included in the approved course of treatment may be subject to a\nseparate pre-authorization.\n * NB Effective January 1, 2027\n (g) When making prospective, concurrent and retrospective\ndeterminations, utilization review agents shall collect only such\ninformation as is necessary to make such determination and shall not\nroutinely require health care providers to numerically code diagnoses or\nprocedures to be considered for certification or routinely request\ncopies of medical records of all patients reviewed. During prospective\nor concurrent review, copies of medical records shall only be required\nwhen necessary to verify that the health care services subject to such\nreview are medically necessary. In such cases, only the necessary or\nrelevant sections of the medical record shall be required. A utilization\nreview agent may request copies of partial or complete medical records\nretrospectively.\n (h) In no event shall information be obtained from the health care\nproviders for the use of the utilization review agent by persons other\nthan health care professionals, medical record technologists or\nadministrative personnel who have received appropriate training.\n (i) The utilization review agent shall not undertake utilization\nreview at the site of the provision of health care services unless the\nutilization review agent:\n (1) I
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