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.
Effective Date: 10-01-1998 .