NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
The date following each state indicates the last time information for the state was reviewed/changed.
Statute
Responsible Agency/Scope
of Coverage
License or Certificate
ALABAMA (8/15)
§§ 27-3A-1 to 27-3A-6; 25-5-293;
Reg. 480-5-5-.01 to 480-5-5-.37
ALASKA (8/15)
No provision
Department of Insurance; covers health care
Department of Industrial Relations; Workers’ Compensation
Division
Health care—Annual certification; $1000 fee.
Workers’ compensation—First level clinical reviewer must have a
valid license or certificate. Second level reviewer must hold a
valid unrestricted license to practice a health profession. Initial
certificate expires 2 years following its effective date unless
renewed for a 2-year term.
Determinations
Health care—Agent reviewing health care must communicate
determination to provider or insured within 2 business days from
receipt of necessary information. Must include principle reason
for determination not to certify. Must include procedures to
initiate an appeal. Must give insured a minimum of 24 hours after
an incident to notify utilization review agent.
Review of Determinations
Health care—Physician in the same or similar specialty must make
determination on appeal. Agents must complete adjudication of
appeals within 30 days from receipt of necessary information.
Attending physician must have an immediate opportunity to
appeal a determination to not certify. Agent must expedite
attending physician’s appeal on expedited basis.
Workers’ compensation—Adverse determinations to precertification requests are subject to peer review and/or
administrative appeal.
Violations
Health care—Insurance department may impose an administrative
fine of not more than $5000 and/or suspend or revoke certificate.
© 2015 National Association of Insurance Commissioners
II-HA-50-1
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
ARIZONA (8/15)
§§ 20-2501 to 20-2511; 20-2530 to 20-2541
ARKANSAS (8/15)
§§ 20-9-901 to 20-9-914; Ark Admin. Code 007.05.5-3
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
State Board of Health; covers health care
License or Certificate
Triennial certification. Agent convicted of misdemeanor involving
moral turpitude or felony or who employs person convicted of a
felony is not permitted to obtain certificate.
Biennial certification; $2500 fee
Determinations
Agent must give reasons for denial of treatment authorization.
Medical director who made denial must sign written denial. Agent
must send copy of written denial to provider who requested
treatment. Must maintain copies of all written denials and make
copies available to insurance department for inspection. Notify
insured of right to proceed to next level of review if prior review
unsuccessful. Must meet other statutory disclosure requirements.
Agent must notify physician and hospital by telephone of
determination not to certify continued length of stay. Must also send
written notification to hospital, attending physician and patient.
Include written reasons for denial and procedure for initiation of
appeal in adverse determination. Director must also receive a copy
of an adverse determination.
Review of Determinations
Insured may pursue appeal process as outlined in agents’
utilization review plan. May pursue expedited medical review if
insured’s treating provider provides requisite documentation.
Agent has one business day to make determination. Must mail
determination to provider and insured. Insured who does not
qualify for expedited medical review may request an informal
reconsideration. May appeal informal reconsideration that is
adverse. May initiate external independent review.
Physician advisor must conduct appeal review. Must be reasonably
available by telephone to discuss the medical basis for the initial
adverse determination with the attending physician. Patient or
provider entitled to additional review by another consulting
physician of the appropriate medical specialty.
Violations
Director may impose a civil fine of up to $2500 or $15,000
depending on nature of violation and/or suspend, revoke or refuse
to renew certificate. Director through the attorney general may file
a complaint in the superior court in the county in which the agent
transacts utilization review business to enjoin and restrain agent
from committing or continuing violation. Agent may request
hearing.
Board may revoke or deny certificate. Agents entitled to
administrative hearing. Violations result in misdemeanor. Penalty up
to $1000.
Statute
© 2015 National Association of Insurance Commissioners
II-HA-50-2
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
CALIFORNIA (8/15)
Ins. § 10123.135
COLORADO (8/15)
§§ 10-4-115; 10-16-112 to 10-16-113.5
Health & Safety § 1363.5
Industrial Reg. tit. 8 §§ 9792.6 to 9792.15
Responsible Agency/Scope
of Coverage
Department of Insurance; health insurance
Department of Insurance; covers health care
Administration of Public Health; covers health care service plans
Department of Industrial Relations; Workers’ Compensation
Division
License or Certificate
No provision
Not licensed
Determinations
Health insurers, health care service plans and workers’
compensation plan administrators must have written procedures
for utilization review. No standards for utilization review agents.
Health care—Utilization review organization providing services to
an insurer or other organization is the direct representative of the
insurer or organization. The insurer is responsible for the actions of
the private review organization acting within the scope of the
contract. Notify insured of denial in writing and explain basis for
denial.
Property casualty insurance—An insurance carrier may contract
with any private utilization review organization and receive from
that private utilization review organization a utilization review
opinion. If the insurance carrier relies on the opinion of the private
utilization review organization resulting in a decision to not pay
benefits that an appropriate fact finder later determines were due and
owing, then the insurance carrier shall be responsible to pay the past
due benefits in addition to interest and costs.
Review of Determinations
Resolved in accordance with Labor Code § 4062.
All denials of care are subject to appeal. The first level appeal shall
be a review by a physician who consults with a peer in a similar
specialty as would manage the case. Second level appeal is a panel
of employees of the health plan with appropriate expertise.
Violations
May assess administrative penalties by order.
No provision
© 2015 National Association of Insurance Commissioners
II-HA-50-3
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
CONNECTICUT (8/15)
No provision
DELAWARE (8/15)
18 Del. Code §§ 6416 to 6420
Responsible Agency/Scope
of Coverage
Department of Insurance; health care
License or Certificate
Reviewers must be physicians or other appropriate health care
practitioners. Hold nonrestricted license in a state of the U.S.
Determinations
Review the pertinent medical records. Review organization shall
complete its review and make its written determination within 45
days of receipt of a completed application for an appeal review.
Review of Determinations
Independent Health Care Appeals Program provides, at a minimum,
a final step in this grievance process. The purpose of the program is
to provide an independent medical necessity or appropriateness of
services review of final decisions of carriers to deny, reduce or
terminate benefits in the event the final decision is contested by the
covered person.
Violations
Commissioner may order a cease and desist from engaging in any
act or practice in violation.
© 2015 National Association of Insurance Commissioners
II-HA-50-4
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
DISTRICT OF COLUMBIA (8/15)
§ 32-1507; 7 DCMR § 232
Responsible Agency/Scope
of Coverage
Mayor’s office; covers workers’ compensation and disability
License or Certificate
No license; utilization review organization must be accredited by
URAC.
Determinations
Medical care decision must be made within 60 days of request.
Review of Determinations
Parties adversely affected may petition the District of Columbia
Court of Appeals for review.
Violations
No provision
© 2015 National Association of Insurance Commissioners
FLORIDA (8/15)
No provision
II-HA-50-5
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
GEORGIA (8/15)
§§ 33-8-1; 33-46-1 to 33-46-14;
GA Comp. R. & Regs. 120-2-58-.01 to 120-2-58-.09;
120-2-80-.07
HAWAII (8/15)
§§ 334B-1 to 334B-8
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
Department of Health; covers mental health, alcohol or drug abuse
treatment
License or Certificate
Biennial certification; $200 fee
No provision
Determinations
Agent shall have sufficient staff to facilitate review in accordance
with review criteria. Give attending health care provider an
opportunity to discuss determination with a representative who is
a health care provider trained in a related medical specialty. Notify
enrollee and attending provider of decision to certify within 2 days
of determination. Notify provider of adverse determination by
telephone within one business day and provide written notification
to enrollee within one business day. Include principal reasons for
determination and instructions for initiating an appeal in written
notification.
Licensed physician or psychologist must review and approve
adverse determination before notification given to attending
provider or patient. Agent must include reasons for denial and
notification of right to appeal in adverse determination.
Review of Determinations
Statutes do not preclude judicial review.
No provision
Violations
Commissioner may suspend, revoke, or refuse to renew certificate.
May also impose fines.
Violations result in a misdemeanor. Penalty up to $1000.
Statute
© 2015 National Association of Insurance Commissioners
II-HA-50-6
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
IDAHO (8/15)
§ 41-3930
ILLINOIS (8/15)
215 ILCS 134/45; 134/85; 50 Ill. Adm. Code 5420.130 to 5420.140
Responsible Agency/Scope
of Coverage
Department of Insurance; covers managed care programs
Department of Insurance; covers health care
License or Certificate
No provision
Biennial registration; $3000 fee. Utilization review organizations
that hold a current accreditation with the URAC, NCQA, or Joint
Commission on Accreditation of Healthcare Organizations pay only
$1500.
Determinations
Managed care organization must provide written explanation of
adverse determination. May not require prior authorization for
emergency services. Respond to requests for prior authorization of
non-emergency services within 2 business days from receipt of
necessary information. Exceptional circumstances may warrant a
longer period to evaluate a request.
Only health care professionals are permitted to make determinations
on the medical necessity of health care services. Plan must base
reviews on medical information available to attending physician at
the time health care services were provided. Must collect only
information that is necessary to make determination.
Review of Determinations
Managed care organization shall provide for timely review of
adverse determinations. Licensed physician, peer provider, or peer
review panel must conduct review.
Enrollee may seek external independent review within 30 days of an
adverse appeal determination. Plan must provide mechanism for
joint selection of an external independent reviewer within 30 days of
request. Independent reviewer must evaluate the appeal within 5
days of receipt of all necessary information. Independent reviewer’s
decision is final.
Violations
No provision
Department may issue a corrective action plan, cease and desist
order.
Statute
© 2015 National Association of Insurance Commissioners
II-HA-50-7
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
INDIANA (8/15)
§§ 27-8-17-1 to 27-8-17-20; 760 IAC 1-46-1 to 1-46-11
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
License or Certificate
Annual certification; $150 fee for initial certificate; $100 fee for renewal certificate.
Determinations
Agent must notify enrollee of determination within 2 business days after receiving a request and all necessary information. Must include
reasons for denial and procedures for initiating an appeal in adverse determination. Determinations must be reviewed by a physician or
according to guidelines approved by a physician.
Review of Determinations
Health care provider licensed in the same discipline as the provider of record must make adverse appeal determination. Agent must
complete appeal determination within 30 days from receipt of necessary information. Must provide expedited appeals process for
emergency situations. Must complete expedited appeal determination within 48 hours from receipt of necessary information.
Violations
Department may impose administrative, civil or criminal penalties. May issue cease and desist order. May order agent to pay civil penalty
of not more than $5000. May suspend or revoke certificate.
© 2015 National Association of Insurance Commissioners
II-HA-50-8
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
IOWA (8/15)
§§ 514F.1 to 514F.6; Reg. 191-70.1 to 191-70.10
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
License or Certificate
License not required. Insurer may not use an agent unless it is certified by URAC, NCQA or other review organization. The utilization
review organization shall provide a copy of the certification to the commissioner. Individuals who are not licensed health care
professionals may perform routine utilization review if they have received full orientation by the organization; they have been fully
trained in the application of medical and/or benefit screening criteria established by the utilization review organization; they have been
trained to refer review requests to licensed health care professionals when the required review exceeds their own expertise; and they are
under the direct supervision of a licensed health care professional.
Determinations
No provision
Review of Determinations
No provision
Violations
Commissioner may suspend authority to conduct reviews.
© 2015 National Association of Insurance Commissioners
II-HA-50-9
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
KANSAS (8/15)
§§ 40-22a01 to 40-22a16
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
License or Certificate
Annual certification; $100 fee; $50 renewal fee
Determinations
Organization must base prospective and concurrent solely on the medical information obtained at the time of the determination. Make
prospective or concurrent determinations within 10 business days from receipt of necessary information and promptly notify attending
health care provider and enrollee of certification determination. When an emergency medical condition exists, the external review shall
provide an expedited resolution within 72 hours after the date of receipt request.
Review of Determinations
Insured has right to request independent external review of an adverse determination when insured has exhausted all available internal
review procedures, when insured has an emergency medical condition, or when insured has not received a final determination from
insurer within 60 days of seeking internal review. Health insurance plan shall notify the insured of the insured’s right to waive the second
appeal or internal review and proceed directly to the external review. External review determination may be subject to judicial review.
Violations
Commissioner may issue cease and desist order. May suspend or revoke certificate. May impose fine of not less than $500 or more than
$1000 for each violation.
© 2015 National Association of Insurance Commissioners
II-HA-50-10
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
KENTUCKY (8/15)
§§ 304.17A-600 to 304.17A-633; 304.18-045; 806 KAR 17:280
Responsible Agency/Scope
of Coverage
Department of Insurance
License or Certificate
$1000 registration and renewal fee
Determinations
Make determination within 24 hours from receipt of request for review of a covered person’s continued hospital and prior to the time
when a previous authorization for hospital care will expire and provide written notice of determinations to enrollee and provider. Provide
reasons for adverse determination and reviewer’s state of licensure, medical license number, etc. Must provide instructions for appeal
procedure and give participating physicians an opportunity to review and comment on insurer protocols. May not revoke approval unless
it was based on materially inaccurate information.
Review of Determinations
Must provide internal appeal determinations within 30 days from receipt of request. Must provide expedited internal appeal determination
within 3 business days from receipt of request. Conduct internal appeal of adverse determination by a licensed physician who did not
participate in the initial review and denial. Must provide instructions for external review of an adverse determination in an appeal
determination.
Violations
Commissioner may deny or revoke certificate. Hearing required.
© 2015 National Association of Insurance Commissioners
II-HA-50-11
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
Responsible Agency/Scope
of Coverage
LOUISIANA (8/15)
§ 22:821; La. Admin Code tit. 40, pt. I, §§ 2701 to 2719
Department of Insurance; covers health care
Department of Employment and Training; Workers’ Compensation Office
License or Certificate
Department of Insurance requires biennial registration; $1500 fee.
Determinations
Health care—a duly licensed physician acting as medical director must administer the program and oversee all review decisions.
Physician or clinical peer must make adverse determinations. Program shall issue determinations in a timely manner. In most instances,
must make determinations within 2 working days from receipt of necessary information and retrospective determinations within 30
working days from receipt of necessary information, but in no case more than 180 days from date of service. Include reasons for an
adverse determination in writing and give provider an opportunity to request informal reconsideration.
Workers’ compensation—insurer must use registered nurses for initial review of recommended hospitalization. Send determination in
writing within 5 calendar days from receipt of authorization request and provide for appeal of any adverse determinations.
Review of Determinations
Health care—program must complete informal reconsideration within one working day from receipt of request. Duly licensed physician
must concur with review panel in a standard appeal. Program must notify parties in writing of determination within 30 working days from
request of appeal. Appeal determination must explain its medical rationale. Program must conduct second level review for each appeal.
Insured must have right to attend second level review; present the case to the review panel; submit supporting material before and at the
review meeting; and direct questions to program representatives. Duly licensed physician and appropriate clinical peer must concur with
adverse determination of the review panel. Program must issue written determination to insured within 5 working days of review meeting.
Workers’ compensation—insurer’s medical director must make a determination within 48 hours from appeal request. Parties may take
appeal further with the Workers’ Compensation Office.
Violations
Insurance commissioner may issue cease and desist orders. May impose civil fines. May suspend or revoke license.
© 2015 National Association of Insurance Commissioners
II-HA-50-12
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
MAINE (8/15)
24-A MRSA §§ 2771 to 2774; Ins. Reg. Ch. 850 § 8
Responsible Agency/Scope
of Coverage
Bureau of Insurance; covers health care
License or Certificate
Annual licensure; $400 application fee; $100 annual fee
Determinations
Program must make non-emergency determinations within 2 business days from authorization request. May not revoke approval
determination unless based on materially incorrect information. Notify insured of right to external review in adverse determination letter.
Review of Determinations
Insured has right to independent external review of insurer’s adverse determination. Insured not required to exhaust insurer’s internal
appeals procedure before filing external review request.
Violations
Insurance superintendent may impose civil penalties not to exceed $1000 for each violation. May deny, suspend or revoke license.
© 2015 National Association of Insurance Commissioners
II-HA-50-13
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
MARYLAND (8/15)
Ins. §§ 15-10B-01 to 15-10B-20; 15-1001 to 15-1010;
Reg. 31.10.21.01 to 31.10.21.11
MASSACHUSETTS (8/15)
176O § 12; 105 CMR 128.200; 128.301 to 128.309; 128.400;
211 CMR 52.08
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
Department of Insurance and Department of Health; covers health
care
License or Certificate
Biennial certification; $1500 fee
No provision
Determinations
Agents must make non-emergency determinations within 2
working days after receipt of necessary information. Must make
extended stay determinations within one working day after receipt
of necessary information. Make adverse determinations through a
physician or appropriate panel. If contracted by insurer, must
provide for appeal process.
Insurer must make admission determination within 2 working days
from receipt of necessary information. Must make concurrent review
determination within one working day from receipt of necessary
information. Must include substantive clinical justification in
adverse determination. Must include procedures for formal internal
grievance process and procedures for obtaining external review.
Review of Determinations
No provision
Insurer must maintain formal internal grievance process, which
provides for expedited review. Must make grievance determination
within 5 days from receipt of grievance submitted by insured with
terminal illness. Must provide for expedited review of grievances.
Must make all other grievance determinations within 30 business
days from receipt of grievance. Must include reasons for denial and
procedures for initiating conference request in adverse
determination. Must schedule a conference within 10 days from
receipt of request. Insured may request an external review within 45
days from receipt of insurer’s final adverse determination
notification.
Violations
Violations result in misdemeanor. Penalty up to $1000.
Commissioner may revoke certificate. Under Ins. § 15-1004,
commissioner may impose penalty up to $5000.
No provision
Statute
© 2015 National Association of Insurance Commissioners
II-HA-50-14
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
MICHIGAN (8/15)
§§ 550.1901 to 550.1929
MINNESOTA (8/15)
§§ 62M.01 to 62M.16
Responsible Agency/Scope
of Coverage
Department of Insurance; health care
Department of Insurance; covers health care
License or Certificate
Approved by the commissioner. Hold nonrestricted license in a
state of the U.S. Physicians must be board certified.
Biennial registration; $1000 fee
Determinations
Except for a request for an expedited review, all requests for an
external review shall be made in writing to the commissioner.
A utilization review organization must have written procedures to
ensure that reviews are conducted in accordance with the
department’s requirements. A utilization review organization may
review ongoing inpatient stays based on the severity or complexity
of the enrollee’s condition or on necessary treatment or discharge
planning activities. A utilization review organization shall have
written procedures for providing notification of its determinations on
all certifications in accordance with this section. An initial
determination on all requests for utilization review must be
communicated to the provider and enrollee within 10 business days
of the request, provided that all information reasonably necessary to
make a determination on the request has been made available to the
utilization review organization.
Review of Determinations
A person aggrieved by an external review decision may seek
judicial review no later than 60 days from the date of the decision
in the circuit court.
Must provide insured and attending provider an opportunity to
appeal by telephone on expedited basis where necessary. Must
notify attending provider by telephone within 72 hours from receipt
of appeal request. For all other appeals, notify provider of appeal
determination within 30 days from receipt of appeal request.
Physician in relevant specialty who did not make the initial
determination must make the appeal determination. Must give notice
of right to external review process.
Violations
Commissioner may issue a cease and desist order. Payment of
civil fine of not more than $1000 per violation.
Commissioner may issue a cease and desist order if utilization
review organization is not properly licensed.
Statute
© 2015 National Association of Insurance Commissioners
II-HA-50-15
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
MISSISSIPPI (8/15)
§§ 41-83-1 to 41-83-31
MISSOURI (8/15)
§§ 374.500 to 374.515; 376.1350 to 376.1389;
20 CSR 400-10.010 to 400-10.250; 700-4.100
Responsible Agency/Scope
of Coverage
Department of Health; covers health care
Department of Insurance; covers health care
License or Certificate
Biennial certification; fee established by Department of Health.
$1000 certificate application fee; $500 annual renewal fee
Determinations
A utilization review organization must demonstrate that it has a
plan that includes a description of review criteria, standards and
procedures to be used in evaluating proposed or delivered hospital
and medical care and the provisions by which patients, physicians
or hospitals may seek reconsideration or appeal of adverse
decisions by the private review agent. The review agent must have
qualified personnel either employed or under contract to perform
the utilization review and have procedures and policies to insure
that a representative of the private review agent is reasonably
accessible to patients and providers at all times in this state.
Insurer is responsible for all utilization review activities carried out
on its behalf. Insurer must issue confirmation number to insured
when the insurer authorizes provision of services. May not retract
prior authorization unless based on material misrepresentation, etc.
Make initial determination within 2 working days from receipt of
necessary information and notify provider within 24 hours of initial
determination. Must notify provider of adverse determination by
telephone within 24 hours. Make retrospective determination within
30 working days from receipt of necessary information. Must
include reasons for adverse determination as well as instructions for
initiating an appeal or reconsideration.
Review of Determinations
Any person aggrieved by final determination of the review agent
has the right to judicial review.
Insurer must complete reconsideration within one working day from
receipt of request. Must be conducted between attending provider
and reviewer who made adverse determination. Insurer must
maintain first and second level grievance review. Must acknowledge
receipt of grievance within 10 working days. Must complete
investigation within 20 working days. Must explain decision in
notice. Must notify aggrieved person within 15 working days after
investigation complete. Must submit second-level grievance to
advisory panel. Must notify enrollee orally within 72 hours from
receipt of request for expedited review. Enrollee may appeal
grievance determination to commissioner or seek judicial review.
Violations
Department may revoke or deny certificate. May impose penalty
of no more than $1000.
May suspend or revoke certificate.
Statute
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II-HA-50-16
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
MONTANA (8/15)
§§ 33-32-101 to 33-32-105; 33-32-201 to 33-32-204; 33-33-101 to 33-33-103; 33-33-201 to 33-33-202
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care and property and casualty
License or Certificate
No license required for health care. Utilization review organizations employed by property and casualty insurers must register with the
commissioner prior to conducting utilization reviews.
Determinations
A person may not conduct a utilization review of health care services provided to a patient covered under a contract or plan for health care
services issued in this state unless that person, at all times, maintains with the commissioner a current utilization review plan that includes
a description of review criteria, standards and procedures to be used in evaluating proposed or delivered health care services that, to the
extent possible, are based on nationally recognized criteria, standards and procedures and reflect community standards of care. Property
and casualty utilization reviews must be conducted by health care professionals who are licensed or certified in the same specialty as the
provider whose treatment is being received by insured. Health care professional conducting review must sign the opinion.
Review of Determinations
Health insurer must attempt to consult with patient’s provider. Reviewer in the same field as provider must conduct review where services
rendered involve licensed social worker, licensed professional counselor, licensed psychiatric nurse, licensed psychiatrist, or licensed
psychologist. Patient may request independent review of patient or provider’s records and has at least 30 days to appeal or seek
reconsideration of adverse determination. Insurer must make final appeal or reconsideration determination within 60 days from receipt of
necessary information.
Violations
No provision
© 2015 National Association of Insurance Commissioners
II-HA-50-17
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
NEBRASKA (8/15)
§§ 44-5416 to 44-5431
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
License or Certificate
Biennial certification; $300 application fee; $100 renewal fee
Determinations
Agent must not offer its employees incentives to make adverse determinations. Insured or attending provider may request an appeal
determination.
Review of Determinations
Insured and attending physician may request appeal of an adverse determination. A physician must be available to review final appeal,
unless care is provided by non-physician provider. Then review should be done by non-physician provider whose practice includes the
same services.
Violations
Penalty for violation shall be a cease and desist order, and possible suspension of certificate and fine of up to $1000 per violation up to
aggregate of $30,000. If violation was “committed flagrantly and in conscious disregard” the fine shall be not more than $15,000 per
violation up to aggregate of $150,000. Penalty for violation of cease and desist order $30,000 per violation up to aggregate $150,000, or
suspension or revocation of certificate..
© 2015 National Association of Insurance Commissioners
II-HA-50-18
NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
NEVADA (8/15)
§§ 683A.375 to 683A.379; NAC 683A.280 to 683A.295
NEW HAMPSHIRE (8/15)
§§ 420-E:1 to 420-E:9; NH ADC Ins. 2001.01 to 2001.18
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
Department of Insurance; covers health care
License or Certificate
Application fee $250; yearly renewal fee $250
Certification fee $500; $100 annual renewal fee
Determinations
An agent that performs utilization review shall have a medical
director who is a physician or, in the case of an agent who reviews
dental services, a dentist, licensed in any state.
A prerequisite for the licensing of a medical utilization review entity
shall be accreditation of the utilization review services performed by
the utilization review entity from URAC or compliance with the
minimal acceptable standards for licensure under NCQA. Review
personnel who are not licensed health professionals may not
communicate directly with insured or provider except to collect and
record demographic information. No claim for benefits shall be
denied nor shall any payment be reduced on the basis of an adverse
medical utilization review determination unless a reasonable,
understandable explanation of the appeals process is given to the
beneficiary.
Review of Determinations
No provision
Entity must establish appeal and reconsideration process.
Violations
Agents are required to be registered before conducting utilization
reviews. Penalty for violation of provision not more than $1000.
Commissioner may impose administrative fine. May deny, suspend
or revoke license.
Statute
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STANDARDS FOR UTILIZATION REVIEW AGENTS
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Statute
NEW JERSEY (8/15)
No provision
NEW MEXICO (8/15)
N.M. Admin Code 13.10.17
Responsible Agency/Scope
of Coverage
Insurance division; health care
License or Certificate
No provision
Determinations
Insurance division staff shall complete initial review within 10
working days from receipt of the request for external review. The
superintendent shall complete the external review within 30 working
days from receipt of the complete request for external review.
Review of Determinations
The superintendent shall conduct a standard review in all cases not
requiring an expedited review.
Violations
No provision
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NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
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Statute
NEW YORK (8/15)
Ins. Law §§ 4900 to 4908; Pub. Health §§ 4900 to 4908
Responsible Agency/Scope
of Coverage
Department of Insurance and Department of Public Health, covers health care. Department of Public Health licenses review entities;
standards for utilization review are found in insurance and health code, reporting requirements in insurance code.
Workers’ Comp. § 732-2.2—Conduct review in manner consistent with standards in public health and insurance laws.
License or Certificate
Biennial registration
Determinations
Medical director must be licensed physician. Establish written procedures for utilization review and appeal of decisions. Only a clinical
peer reviewer (a licensed professional in similar specialty as health care provider) may render an adverse determination. Must have
written procedures for keeping information confidential. Include instructions for initiating standard and expedited appeal. Must make a
pre-authorization determination by telephone and in writing within 3 business days from receipt of necessary information and continued
treatment determination within one business day from receipt of necessary information. Written notification is to be transmitted
electronically, in a manner agreed upon by the parties. May not make adverse determination based on lack of consent to observe health
care service.
Review of Determinations
Agent must establish expedited appeal process. Shall provide reasonable access to its clinical peer reviewer within one business day from
receipt of notice for expedited appeal. Shall make expedited appeal determination within 2 business days from receipt of necessary
information. Inform enrollee of right to external review.
Violations
No provision
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NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
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Statute
NORTH CAROLINA (8/15)
§ 58-50-61
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
License or Certificate
No license required. Insurer is responsible for the activities of the utilization review agents.
Determinations
Qualified health care professionals must administer program and oversee review decisions under the direction of a medical doctor.
Licensed medical doctor must evaluate the clinical appropriateness of adverse determinations. Insurer shall make prospective and
concurrent determinations within 3 business days from receipt of necessary information and notify provider of adverse determination in
writing; include reasons for adverse determination in notice. Must include instructions for initiation of appeal.
Review of Determinations
Insurer may not require insured to participate in informal reconsideration before permitting appeal of adverse determination. Make nonexpedited appeal determination within 30 business days from receipt of request and expedited appeal determination within 4 days from
receipt of information justifying expedited review. Must include professional qualifications of reviewer, statement of insured’s appeal
rationale, explanation of adverse determination, etc.
Violations
Commissioner may impose civil penalties.
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STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
NORTH DAKOTA (8/15)
§§ 26.1-26.4-01 to 26.1-26.4-05; NDAC 45-06-10-01 &
45-06-10-02
OHIO (8/15)
§§ 1751.77 to 1751.89
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
Department of Insurance; covers health care
License or Certificate
Department of Insurance requires annual certification.
No license requirement. Must annually file certificate with
commissioner certifying compliance with appropriate statutes.
Health insuring corporation is responsible for the actions of the
utilization review organization it uses..
Determinations
Determinations must be reviewed by a physician or, if appropriate,
a licensed psychologist, or determined in accordance with
standards they develop. Give notice of determination to enrollee
according to statutory time limits. A licensed health professional
must review agent’s determination. Utilization review agent must
include statutorily required disclosures in an adverse
determination. Agent may not require prior authorization of
emergency services.
Qualified providers must administer the program and oversee review
determinations. Make prospective determination within 2 business
days from receipt of necessary information and notify provider
within 3 business days from initial determination. Make concurrent
review determinations within one business day from receipt of
necessary information and notify provider by telephone or fax
within one business day from determination. Must include reasons
for denial in all adverse determinations and instructions for initiating
reconsideration of determination.
Review of Determinations
Health professionals must make adverse appeal determination.
Agent must include evaluation findings and concurrence of a
physician trained in relevant specialty in adverse appeal
determination.
Clinical peer in the same or similar specialty as manages the medical
service under review must evaluate the clinical appropriateness of
adverse determinations that are the subject of an appeal.
Statute
Violations
Penalty of up to $10,000 may be assessed for a violation of
provision. May suspend or revoke agent’s authority to do business
in the state.
© 2015 National Association of Insurance Commissioners
The superintendent of insurance shall establish and maintain a
system for receiving and reviewing requests for review from or on
behalf of enrollees who have been denied coverage of a health care
service or had coverage reduced or terminated.
A violation is an unfair trade practice.
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NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
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OKLAHOMA (8/15)
tit. 36, §§ 6551 to 6565; OAC 365:10-15-1 to 365:10-15-7
OREGON (8/15)
§§ 743.806 to 743.807
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
Department of Insurance; covers health care
License or Certificate
Annual certification with a $500 fee.
No license requirement. Insurer is responsible for the actions of the
utilization review agent.
Determinations
A utilization review organization must have a plan that includes
adequate review standards, protocol and procedures to be used in
evaluating proposed or delivered hospital and medical care and
assurances that the standards and criteria to be applied in review
determinations are established with input from health care
providers representing major areas of specialty and certified by
the boards of the various American medical specialties. Utilization
review agents must have provisions by which patients or health
care providers may seek reconsideration or appeal of adverse
decisions by the private review agent. Procedures must be in place
to ensure that a representative of the private review agent is
reasonably accessible to patients and health care providers 5 days
a week during normal business hours. Procedures must be in place
to ensure that a copy of the report of a private review agent
concerning a rejection will be mailed by the insurer, to the ill
person, the treating health care provider or to the person
financially responsible for the patient’s bill within 15 days after
receipt of the request for the report.
Licensed doctor of medicine or osteopathy must be responsible for
final recommendations regarding necessity or appropriateness of
services or site at which services are provided. Must consult with
appropriate medical and mental health specialists. Must make nonemergency service determination within 2 business days. Qualified
health care personnel must be available for same-day telephone
response.
Review of Determinations
Qualified health care professionals must actively participate in
agent’s appeal and complaint process.
Insurer must give patient or provider opportunity to appeal.
Violations
Insurance commissioner may refuse, deny, suspend or revoke
certificate. May impose civil penalties of not less than $100 no
more than $1000 for each occurrence.
No provision
Statute
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NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
Responsible Agency/Scope
of Coverage
License or Certificate
PENNSYLVANIA (8/15)
40 P.S. §§ 991.2151 & 991.2152; 31 Pa. Code §§ 69.51 to 69.55; 34 Pa. Code §§ 122.612; 127.404; 127.471
Department of Insurance; covers health care and automobile insurance
Department of Labor and Industry; covers workers’ compensation
Health care utilization review entities must obtain triennially-renewed certification. May rely on nationally recognized accrediting body’s
standards to certify agents.
Automobile peer review organization must obtain commissioner’s approval to contract with an insurer.
Workers’ compensation; department of labor and industry must approve independent utilization review organization.
Determinations
Licensed physician must make adverse determination. Licensed psychologist may perform limited utilization review. Must ensure that
personnel conducting review have current licenses in good standing without restrictions from appropriate agency. Health care entity must
communicate prospective determination within 2 business days from receipt of necessary information and concurrent determination
within one business day from receipt of necessary information. Must include basis for determination. Health care review entity must
respond to each telephone message within one business day from receipt of call.
Automobile insurers must make a referral to a peer review organization within 90 days from receipt of sufficient documentation
supporting the bill. Peer review organization must make determination within 30 days from receipt of requested information. Provide
written determination, which includes reasoning. Licensed practitioner of like specialty must make adverse determination.
In workers’ compensation, coordinated care organization must make prospective determination within 7 days of request. Use qualified
and experienced registered nurses to make initial determinations; base adverse determinations on clinical review by a qualified physician
or practitioner.
Review of Determinations
In workers’ compensation, coordinated care organization must make appeal determination within 7 days of request.
Automobile insurer or provider may request reconsideration of initial determination within 30 days from its effect. Peer review
organization must complete reconsideration within 30 days from receipt of necessary information. Parties may seek judicial review.
Violations
No provision
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NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
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Statute
PUERTO RICO (8/15)
No provision
RHODE ISLAND (8/15)
§§ 23-17.12-1 to 23-17.12-17;
R.I. Admin. Code 31-1-23:1.0 to 31-1-23:14.0
Responsible Agency/Scope
of Coverage
Department of Health and Safety; covers health care
License or Certificate
Biennial certification; $500 fee
Determinations
Utilization review agents must consult with no fewer than 5 licensed
physicians or other health care providers. Notify provider and
patient of prospective determination within one business day from
receipt of necessary information. Notify provider and patient of
concurrent determination prior to end of current certified period and
of retrospective determination within 30 business days from receipt
of necessary information. Agent shall make non-emergency
determinations within 7 business days from receipt of necessary
information. Must include reasons for denial and procedure to
initiate appeal in adverse determination. Licensed practitioner must
make, document and sign adverse determination.
Review of Determinations
Agent must provide for two-level internal appeal process. Must
provide expedited appeals process for emergency or life threatening
situations. Must complete expedited appeal determination within 2
business days from request and receipt of necessary information.
Agent must provide for external appeal process.
Violations
Department may revoke certificate and/or impose reasonable
monetary penalties not to exceed $5000 per violation. Person who
submits false information is guilty of misdemeanor and is subject to
a $5000 penalty.
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NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
SOUTH CAROLINA (8/15)
§§ 38-70-10 to 38-70-60; Reg. 69-47
SOUTH DAKOTA (8/15)
§§ 58-17H-1 to 58-17H-49; 58-17D-1 to 58-17D-7;
SD Admin. R. 20:06:33:01 to 20:06:33:04
Responsible Agency/Scope
of Coverage
Department of Insurance; covers insurance companies generally
Department of Insurance; covers health care and property and
casualty
License or Certificate
$400 application fee; $800 biennial certification fee
Annual registration with a $250 fee. Provision applies to health care
insurers and property and casualty insurers. The health carrier is
responsible for monitoring activity of the utilization review agent.
Determinations
Must have sufficient registered nurses and medical records
technicians, supervised by physicians, to carry out duties. Private
agent must include length of stay and date of next review in
certification. Must include required disclosure language in
notification of certification. Must notify insured by telephone or
fax of adverse determination. Must include reasons for denial, and
procedure for appeal in adverse determination. Agent must have
written procedures for assuring patient confidentiality and timely
responses.
Qualified licensed health care professionals must administer
utilization review program and oversee review decisions. Must
evaluate adverse determinations. Insurer must collect only
information necessary to make determination. Must make
prospective determination within 15 days from receipt of request
and make retrospective determinations within 30 days from receipt
of request. Must include reasons for denial and procedure for appeal
in adverse determination notification.
Statute
Property and casualty insurers may use only registered utilization
review organizations.
Review of Determinations
Private agent must notify insured of appeal determination within
30 days from receipt of necessary information. Must communicate
expedited appeal determination within 2 working days from
receipt of necessary information.
No provision
Violations
Commissioner may impose administrative fine not to exceed
$1000 per violation. May deny, suspend, or revoke certificate.
No provision
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NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
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Statute
Responsible Agency/Scope
of Coverage
TENNESSEE (8/15)
§§ 56-6-701 to 56-6-706; Tenn. Comp. R. & Regs. tit. 0800, Ch. 02-06-.01 to 02-06-.12
Department of Insurance; covers health care
Department of Labor; covers workers’ compensation
License or Certificate
Department of insurance requires annual certification; $1000 fee. Agent certified by the URAC is exempt from fee.
Determinations
Health care—agent must notify provider and insured of determination within 2 business days from receipt of determination request.
Physician must review determination on appropriateness of admission, service, or procedure. Agent must include reasons for denial and
procedure to initiate an appeal in adverse determination.
Workers’ compensation—agent must make determination based on medically accepted standards and objective evaluation of
circumstances. Must verbally notify provider and insured within 24 hours of determination.
Review of Determinations
Health care—physician in like specialty must make adverse appeal determination. Agent must complete appeal determinations within 30
days from receipt of necessary information. Must complete expedited appeal within 48 hours from receipt of necessary information.
Workers’ compensation—any party may request medical director to review agent’s determination.
Violations
Commissioner may impose a penalty of up to $10,000 in the aggregate. May suspend or revoke agent’s authority to act as a utilization
review agent.
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STANDARDS FOR UTILIZATION REVIEW AGENTS
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Statute
TEXAS (8/15)
I.C. §§ 4201.103; 4201.105; 4201.204; 28 TAC §§ 12.1 to 12.6; 19.1701 to 19.1719
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care and workers’ compensation
License or Certificate
Set by commissioner.
Determinations
Health care—agent is not permitted to observe examination or treatment of insured without insured’s permission. Must conduct utilization
review under the direction of a licensed physician. May not engage in unnecessary or unreasonable repetitive contacts with provider or
insured. Must base frequency of contacts on severity or complexity of insured’s condition. Licensed health provider must supervise
specialty agent. Provider must have opportunity to discuss treatment with agent when agent questions medical appropriateness of health
care services. Agents must communicate determination within 2 working days from receipt of necessary information. Must include
reasons for denial, and procedure for initiation of an appeal in adverse determination. Must notify provider by telephone or electronic
transmission within one working day of adverse determination.
Workers’ compensation—agents must not observe, participate, or record examination or treatment of insured unless insured gives
permission. Must give name and name of organization for on-site reviews. Must carry picture identification and company identification
card with certification number. Must give reasons for denial, and procedure for initiation of appeal process in adverse determination.
Provider must have opportunity to discuss treatment for insured where agent questions the appropriateness of health care services. Agent
must base retrospective determination on written criteria established by physicians. Must make retrospective determination under the
direction of a physician and notify provider of opportunity to appeal adverse determination.
Review of Determinations
Agent must provide specialty review for adverse appeal determinations. Must complete expedited appeal procedure within one working
day from receipt of necessary information. Must include reason for denial, and procedure for independent review in adverse
determination. Agent must not reverse appeal determination in favor of insured. Physician must conduct reconsideration and appeal
reviews according to standards developed from appropriate providers. Specialty review agent must complete appeal determination within
15 working days from receipt of request.
Violations
Commissioner may issue a cease and desist order. May assess administrative penalties. May revoke or suspend certificate.
Workers’ compensation—a person performing utilization review without a certificate commits a class A misdemeanor.
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NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
UTAH (8/15)
No provision
VERMONT (8/15)
tit. 8, § 4089a; VT ADC 4-5-3:10.100 to 4-5-3:10.600
Responsible Agency/Scope
of Coverage
Department of Insurance; covers mental health
License or Certificate
Annual licensure; $200 fee
Determinations
Agent must engage licensed mental health providers to conduct all
review services. Must include evaluation, findings, and concurrence
of mental health professional in adverse determination. Must make
determination only after communication with insured’s mental
health professional. Must disclose to insured and provider procedure
to initiate appeal.
Review of Determinations
Agent must have internal appeal procedure. Must conduct expedited
internal appeal in emergencies and notify insured and provider of
appeal determination within 10 days of request.
Violations
Commissioner may impose $5000 fine for each violation.
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NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
11/15
Statute
VIRGIN ISLANDS (8/15)
No provision
Responsible Agency/Scope
of Coverage
License or Certificate
Determinations
Review of Determinations
Violations
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STANDARDS FOR UTILIZATION REVIEW AGENTS
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Statute
VIRGINIA (8/15)
§§ 32.1-137.7 to 32.1-137.17; 32.1-138.6 to 32.1-138.15; 12 VAC §§ 5-405-10 to 5-405-120
Responsible Agency/Scope
of Coverage
Department of Health; covers health care
License or Certificate
Private review agent must obtain certificate of registration from the department of health. Biennial certification with $500 fee.
Determinations
Agent’s staff who are responsible for making determinations must have qualifications equivalent or exceeding those of Accredited Record
Technicians as awarded by the American Medical Record Association. The private review agent shall have available the services of a
sufficient number of medical records technicians, licensed practical nurses, registered nurses, or other similarly qualified professionals,
supported and supervised by appropriate licensed physicians, to carry out its utilization review activities. The staff shall include nonphysician providers, as appropriate, and physicians in appropriate specialty areas. The physician staff shall include physicians who are
board certified or board eligible. Agent must notify provider in writing within 2 working days of adverse determination. Agent must
include reasons for denial, and procedure for initiation of appeal in written adverse determination.
Review of Determinations
Entity must use services of physician advisors who are specialists in the various categories of health care on as “per need” or “as needed”
basis for utilization review. Notify insured or provider within 60 working days from receipt of necessary information. Must include
reasons for denial and procedure for initiation of appeal in adverse determination. Peer of treating provider must review appeal.
Reviewing peer must not have participated in original adverse determination; must not be employed by the entity; and must be licensed to
practice. Entity must permit insured or provider to present additional evidence on appeal. Agent must make regular appeal determination
within 60 days from receipt of necessary information and expedited appeal determination within one business day from receipt of
necessary information. Physician advisor or peer provider must review appeal for agent.
Violations
Department may deny or revoke agent’s certificate.
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STANDARDS FOR UTILIZATION REVIEW AGENTS
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Statute
WASHINGTON (8/15)
No provision
WEST VIRGINIA (8/15)
W. Va. Code R. §§ 114-51-1 to 114-51-4
Responsible Agency/Scope
of Coverage
Department of Insurance; HMOs
License or Certificate
Duly licensed physician shall conduct a review of medical
appropriateness on any denial of medical services.
Determinations
Must have written utilization review decision protocols based on
reasonable medical evidence.
Review of Determinations
No provision
Violations
No provision
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NAIC’s Compendium of State Laws on Insurance Topics
STANDARDS FOR UTILIZATION REVIEW AGENTS
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Statute
WISCONSIN (8/15)
Wis. Admin. Code Ins. §§ 18.01 to 18.16
Responsible Agency/Scope
of Coverage
Department of Insurance; covers health care
License or Certificate
No provision
Determinations
Insurer offering health benefit plan shall develop an internal
grievance and expedited grievance procedure.
Review of Determinations
No provision
Violations
No provision
WYOMING (8/15)
No provision
This chart does not constitute a formal legal opinion by the NAIC staff on the provisions of state law and should not be relied upon as such. Every effort has been made to provide correct and accurate
summaries to assist the reader in targeting useful information. For further details, the statutes and regulations cited should be consulted. The NAIC attempts to provide current information; however,
readers should consult state law for additional adoptions.
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