HB 899 -- Health Care Utilization Review

Sponsor:  Colona

This bill changes the laws regarding the state's health care
utilization review process to comply with federal laws and
regulations.  In its main provisions, the bill:

(1)  Requires a health carrier to maintain records for at least
six years for all benefit requests and claims and for notices
associated with utilization review and benefit determinations;

(2)  Allows a covered person to file a request for an external
review if a health carrier fails to strictly adhere to the
requirements regarding making utilization review and benefit
determinations of a benefit request or claim;

(3)  Requires a health carrier to ensure that the utilization
review is conducted in a manner to make certain the independence
and impartiality of the individuals in making the utilization
review or benefit determination;

(4)  Prohibits a health carrier from making a decision regarding
hiring, compensation, termination, promotion, or other similar
matters based upon the likelihood that the individual will
support the denial of benefits;

(5)  Requires a written notification of an adverse determination
to include information sufficient to identify the specific claim
and the specific reason for the denial and to provide the
required notice in a culturally and linguistically appropriate
manner if required in accordance with federal regulations;

(6)  Requires a health carrier that provides emergency service
coverage to cover services to screen and stabilize a covered
person without the need for prior authorization under certain
situations, without the provider being in the network, and
without the imposition of an administrative requirement or
limitation on coverage for an out-of-network provider that is
more restrictive than the requirements or limitations that apply
to emergency services received from an in-network provider;

(7)  Requires a health carrier to maintain a written register of
all grievances received during the year, including the notices
and claims associated with the grievances, and to retain the
required information for six years.  The health carrier must make
the records available for examination to the enrollee; the
Director of the Department of Insurance, Financial Institutions
and Professional Registration; and appropriate federal oversight
agencies upon request;

(8)  Specifies that if a health carrier fails to strictly adhere
to the provisions regarding receiving and resolving grievances
involving an adverse determination, an enrollee must be deemed to
have exhausted all efforts and can file for an external review;

(9)  Requires every health carrier to establish a grievance
review process.  Currently, only a health carrier that offers
managed care plans must establish a first- and second-level
grievance review process;

(10)  Requires, prior to issuing a decision, a health carrier to
provide free of charge to the enrollee or his or her authorized
representative any new or additional evidence in connection with
a grievance or final adverse determination to a covered person
within a time period that allows the covered person or the
representative a reasonable opportunity to respond;

(11)  Requires a health carrier that offers managed care plans to
establish a second-level review process for its managed care
plans;

(12)  Requires the department director to resolve any grievance
regarding a final adverse determination based on medical
necessity, appropriateness, health care setting, level of care,
or effectiveness of a covered service when appealed by an
enrollee or health carrier or plan sponsor through a referral to
an independent review organization.  Currently, the department
director must resolve any grievance regarding an adverse
determination;

(13)  Requires the department director to approve independent
review organizations eligible to be assigned to conduct external
reviews.  Currently, the department director must establish the
qualifications for the review organizations;

(14)  Reduces, from 72 hours to 24 hours, the time period that a
health carrier has to orally notify an enrollee after receiving a
request for an expedited review of a carrier's determination;

(15)  Removes the provision which specifies that the requirements
regarding health care utilization review are not applicable to
health indemnity plans without a managed care component; and

(16)  Prohibits a health care provider from charging a fee to a
patient for the reproduction or copying of health care records or
health information provided to the Division of Consumer Affairs
within the department under specified conditions.

Missouri House of Representatives
96th General Assembly, 1st Regular Session
Last Updated August 9, 2011 at 1:26 pm