Effective: October 1, 1998 Latest Legislation: House Bill 361 - 122nd General Assembly A health insuring corporation that conducts utilization review shall prepare a written utilization review program that describes all review activities, both delegated and nondelegated, for covered health care services provided, including the following: (A) Procedures to evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services; (B) The use of data sources and clinical review criteria in making decisions; (C) Mechanisms to ensure consistent application of criteria and compatible decisions; (D) Data collection processes and analytical methods used in assessing utilization of health care services; (E) Mechanisms for assuring confidentiality of clinical and proprietary information; (F) The periodic assessment of utilization review activities, and the reporting of these assessments to the health insuring corporation's board, by a utilization review committee, a quality assurance committee, or any similar committee; (G) The functional responsibility for day-to-day program management by staff; (H) Defined methods by which guidelines are approved and communicated to providers and health care facilities.
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