§2344. Utilization review services

As used in this subchapter, unless the context indicates otherwise, "utilization review services" or "medical utilization review services" means a program or process by which a person, partnership or corporation, on behalf of an insurer, nonprofit service organization, 3rd-party administrator, or health maintenance organization, preferred provider organization or employer that is a payor for or that arranges for payment of medical services, seeks to review the utilization, appropriateness or quality of medical services provided to a person whose medical services are paid for, partially or entirely, by that insurer, nonprofit service organization, 3rd-party administrator, health maintenance organization, preferred provider organization or employer. The terms include these programs or processes whether they apply prospectively or retrospectively to medical services. Utilization review services include, but are not limited to, the following:   [PL 1993, c. 602, §3 (AMD).]

1.  Second opinion programs.  Second opinion programs;

[PL 1989, c. 556, Pt. C, §1 (NEW).]

2.  Prehospital admission certification.  Prehospital admission certification;

[PL 1989, c. 556, Pt. C, §1 (NEW).]

3.  Preinpatient service eligibility certification.  Preinpatient service eligibility certification; and

[PL 1989, c. 556, Pt. C, §1 (NEW).]

4.  Concurrent hospital review.  Concurrent hospital review to determine appropriate length of stay.

[PL 1989, c. 556, Pt. C, §1 (NEW).]

SECTION HISTORY

PL 1989, c. 556, §C1 (NEW). PL 1993, c. 602, §3 (AMD).