A. Each utilization review agent shall:

1. 1. Adopt a written utilization review plan with standards and criteria that apply to all utilization review determinations and that are objective, clinically valid and compatible with established principles of health care.
2. 2. Establish the utilization review plan with input from physician advisors who represent major medical specialties and who are certified or board eligible under the standards of the appropriate American medical specialty board.
3. 3. Include in the adopted utilization review plan a process for prompt initial reconsideration of an adverse determination and a process for appeals that meet the requirements of this article. This paragraph does not apply to utilization review activities limited to retrospective claims review.

F. On or before March 1 of each year after the year in which the utilization review agent filed the notice prescribed in subsection E of this section, the utilization review agent or the agent's successor shall submit a signed and notarized annual report to the director that includes the designated location for review and inspection by the director or the director's authorized representative and that certifies that:

1. 1. The utilization review plan and all modifications remain in compliance with the requirements of this section.
2. 2. The utilization review agent will conduct all utilization reviews in accordance with the plan.
3. 3. All adverse determinations made in the prior year were based on the plan in effect on the date of those adverse determinations.

G. On written request, the utilization review agent shall provide copies to any member or the member's treating provider of:

1. 1. Those portions of the utilization review agent's utilization review plan that are relevant to the request for a covered service or claim for a covered service.
2. 2. The protocols or guidelines that were used if the standards and criteria adopted are based on protocols or guidelines developed by an American medical specialty board.