(b) A private review agent seeking certification shall:

1. (1) Submit an application to the secretary in a form that the secretary requires;

2. (2)

   1. (A) Pay an application fee of one thousand two hundred fifty dollars ($1,250) per year.
   2. (B) This fee is payable in advance for both years of the certification (total two thousand five hundred ($2,500)).
   3. (C) This fee applies to the entity doing the review and not to the individual reviewer; and
3. (3) Provide supporting documentation as required by this part.

(c) An application for certification shall be accompanied by all of the following:

1. (1)

   1. (A) A utilization review plan, which shall include any or all of the following components used by the private review agent to:

(i) Approve or deny payment;

1. (ii) Recommend approval or denial of payment in advance for proposed or delivered inpatient or outpatient care; or

   1. (iii) Retrospectively approve or deny under certain circumstances.

   2. (B) Elements of review such as:

      1. (i) Prospective review (includes preadmission, admission, and preauthorization);
      2. (ii) Concurrent or continued stay review;
      3. (iii) Reconsideration;
      4. (iv) Second surgical opinion;
      5. (v) Noncertification or nonauthorization;
      6. (vi) Lack of information or administrative denial;
      7. (vii) Retrospective review; and
      8. (viii) Bill review.

   3. (C) Policies and procedures for review including:

      1. (i) Any forms or form letters used during the review process;
      2. (ii) Time frames that shall be met during the review; and
      3. (iii) A written protocol describing every aspect of the review process.
   4. (D) A description of the clinical review criteria and the policies and procedures for updating or modification.
   5. (E) Review delegation and oversight policies and procedures.

   6. (F) The provisions, procedures, and time frames by which patients, physicians, or hospitals may seek appeal of an adverse determination by the private review agent including:

      1. (i) A written protocol describing the appeal procedure;
      2. (ii) Any forms or form letters which shall be used during the appeal procedure;
      3. (iii) Time frames that shall be met during the appeal procedure; and
      4. (iv) The names and qualifications of personnel making final appeal determinations.
   7. (G) Quality management program policies and procedures.
   8. (H) Case management policies and procedures;

2. (2)

   1. (A) The name, number, type, and qualification or qualifications of the personnel either employed or under contract to perform the utilization review.
   2. (B) Any change in the medical director shall be reported to the secretary within thirty (30) days;

3. (3) Policies and procedures to verify the current licensure and credentials of:

   1. (A) Utilization review personnel;
   2. (B) Consulting and appeal physicians;
   3. (C) Chiropractic physicians; and
   4. (D) Dentists;

4. (4)

   1. (A) Policies and procedures to ensure that a:

      1. (i) Representative of the private review agent is accessible to patients and providers five (5) days a week during normal business hours in this state; and
      2. (ii) Free telephone number be provided with adequate lines available and staffed.
   2. (B) The procedure for handling after-hours, weekend, and holiday inquires shall be specified;
5. (5) The policies and procedures to ensure that all applicable state and federal laws to protect the privacy, security, and confidentiality of individual health information are followed;
6. (6) A copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan; and

7. (7) A list of the health plans, health insurers, third-party payers, or others for which the private review agent is performing utilization review in this state.

   1. (d) A certificate of registration is not transferable.

(e) The application information and all supporting documents as provided by Acts 1989, No. 537 shall:

1. (1) Be held in confidence; and
2. (2) Not disclosed to the public.