1. (a) A health care insurer that requires utilization review of a benefit request under a health care insurance policy shall develop and implement a written utilization review program that describes, at a minimum, the following utilization review activities:

   1. (1) filing of a benefit request;
   2. (2) notification to a covered person or the covered person's authorized representative of a utilization review and benefit determination;
   3. (3) review of an adverse determination under 3 AAC 28.930 - 3 AAC 28.938.

2. (b) The written document required under (a) of this section must describe

   1. (1) procedures to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services;
   2. (2) data sources and clinical review criteria used in making a determination;
   3. (3) procedures to ensure consistent application of clinical review criteria and compatible determinations;
   4. (4) data collection processes and analytical methods used to assess utilization of health care services;
   5. (5) provisions to ensure the confidentiality of clinical, proprietary, and protected health information;
   6. (6) the health care insurer's organizational mechanism, such as a utilization review committee or quality assurance or other committee, that periodically assesses the health care insurer's utilization review program and reports to the health care insurer's governing body; and
   7. (7) the position title for the health care insurer's staff member that is responsible for the day-to-day management of the utilization review program.

(Eff. 3/15/2018, Register 225)

Authority: AS 21.06.090, AS 21.07.005