§ 27-20.11-4. Medical necessity and appropriateness of treatment. (a) Upon request of the reimbursing health insurance carrier, all providers shall furnish medical records or other necessary data which substantiates that initial or continued treatment is at all times medically necessary and appropriate.

(b) Medical necessity criteria may be based in part on evidence of continued improvement as a result of treatment. When the provider cannot establish the medical necessity and/or appropriateness of the treatment modality being provided, neither the health insurer nor the patient shall be obligated to reimburse for that period or type of care that was not established. The exception to the preceding can only be made if the patient has been informed of the provisions of this subsection and has agreed in writing to continue to receive treatment at his or her own expense.

(c) Any subscriber who is aggrieved by a denial of benefits provided under this chapter may appeal a denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of title 23.

(d) A health insurance carrier may require submission of a treatment plan, including the frequency and duration of treatment, signed by a child psychiatrist, a behavioral developmental pediatrician, a child neurologist or a licensed psychologist with training in child psychology, that the treatment is medically necessary for the patient and is consistent with nationally recognized treatment standards for the condition such as those set forth by the American Academy of Pediatrics. An insurer may require an updated treatment plan no more frequently than on a quarterly basis.

History of Section. (P.L. 2011, ch. 159, § 1; P.L. 2011, ch. 175, § 1.)