PURPOSE: This rule sets forth the procedure for a utilization review agent to obtain a certificate of registration and prescribes the standards to which the utilization review agent must adhere in order to conduct utilization review in this state. This rule is adopted pursuant to section 374.515, RSMo and implements sections 374.500–374.515, RSMo.

1. (1) A utilization review agent may not conduct utilization review in this state without a certificate of registration issued by the director of Department of Insurance, Financial Institutions and Professional Registration (the director). The application for a certificate shall be submitted to the department on the form approved by this rule. The application shall be signed by the applicant or, if the applicant is a corporation, by an officer or, if the applicant is a partnership, by one (1) of the partners. The application shall be accompanied by an application fee of one thousand dollars ($1,000).

2. (2) Each application for renewal shall—

   1. (A) Be submitted on the form approved by this rule;
   2. (B) Be accompanied by a renewal fee of five hundred dollars ($500). The certificate of registration issued to a utilization review agent shall be renewed annually on or before the anniversary date of the initial certificate as shown on the original certification; and
   3. (C) Be accompanied by a list of the utilization review agent’s current health plan clients with contact information for each such health plan client. A list of the health plan’s clients is not required to accompany the application.
3. (3) Failure to renew a certificate of registration in a timely manner shall result in a fine as set forth in section 374.280, RSMo.
4. (4) Pursuant to sections 374.046 and 374.512, RSMo, the director may take action against any utilization review agent doing business in this state without a certificate of registration in violation of section 374.503, RSMo, even if the principal place of business of the utilization review agent is located in another state.
5. (5) Any utilization review agent doing business in this state under a name other than its true name shall file with the director a copy of all documents, including the authorization from the Missouri Secretary of State which shows the legal authority for the utilization review agent to use such other name. Even though multiple names may be registered with the Missouri Secretary of State, the utilization review agent must choose only one
6. (1) authorized name for a certificate of authority to conduct business as a utilization review agent.

7. (6) Per section 374.510, RSMo, the minimum requirements for sections 376.1350 to 376.1399, RSMo, shall apply to utilization review agents. Such requirements include, but are not limited to, the following:

   1. (A) Any medical director who administers the utilization review program or oversees the review decisions shall be a qualified health care professional licensed in the state of Missouri. A licensed clinical peer shall evaluate the clinical appropriateness of adverse determinations;
   2. (B) Utilization review decisions shall be made and issued in a timely manner pursuant to the requirements of sections 376.1363, 376.1365 and 376.1367, RSMo;
   3. (C) A utilization review agent shall provide health plan enrollees and health plan participating providers with timely access to its review staff by a toll-free number;
   4. (D) When conducting utilization review, the utilization review agent shall collect only the information necessary to certify the admission, procedure or treatment, length of stay, frequency and duration of services. No utilization review agent shall require or request a Federal Drug Enforcement Administration Number or a Missouri Controlled Substance Registration Number from any provider;
   5. (E) Compensation to persons providing utilization review services for a utilization review agent shall not contain direct or indirect incentives for such persons to make medically inappropriate review decisions. Compensation to any such persons may not be directly or indirectly based on the quantity or type of adverse determinations rendered;
   6. (F) If a utilization review agent is responsible for pre-approving any covered benefits or services, then the utilization review agent shall issue a confirmation number to the enrollee when it authorizes the provision of health care services; and
   7. (G) If a utilization review agent authorizes the provision of health care services, the utilization review agent shall not subsequently 20 CSR 700-4

retract its authorization after the health care services have been provided, or reduce payment for an item or service furnished in reliance on approval, unless:

1. 1. Such authorization is based on a

material misrepresentation or omission about the treated person’s health condition or the cause of the health condition; or

1. 2. The health benefit plan terminates

before the health care services are provided; or

1. 3. The covered person’s coverage under

the health benefit plan terminates before the health care services are provided.

1. (7) The following form has been adopted and approved for filing with the department:

   1. (A) Utilization Review Agent Application for Certificate of Registration (“Form UR1”), or any form which substantially comports with the specified form.
2. (8) The department on request will supply in printed format the forms listed in this rule. Accurate reproduction of the forms may be utilized for filing in lieu of the printed forms. All application forms referenced herein are available at http://www.insurance.mo.gov.

AUTHORITY: sections 374.515 and 376.1399, RSMo 2000.* Emergency rule filed Nov. 1, 1991, effective Nov. 11, 1991, expired March 10, 1992. Original rule filed Nov. 1, 1991, effective May 14, 1992. Amended: Filed Aug. 26, 1993, effective May 9, 1994. Amended: Filed Nov. 3, 1997, effective May 30, 1998. Amended: Filed April 23, 1999, effective Nov. 30, 1999. Amended: Filed March 28, 2007, effective Oct. 30, 2007. *Original authority 374.515, RSMo 1991, amended 1993; and 376.1399, RSMo 1997, amended 1997.