1. (a) No claim for benefits shall be denied or payment reduced on the basis of an adverse medical utilization review determination except in accordance with RSA 420-E:4.
2. (b) All hospital preadmission review programs shall include specific provisions concerning immediate hospitalization of a beneficiary for whom the treating physician determines the admission to be an emergency, including subsequent documentation of medical necessity.
3. (c) Preadmission inpatient service eligibility programs shall include, but not be limited to, a review of the medical necessity for admission to a skilled nursing facility, intermediate care facility, or other long term care facility as defined in the applicable health insurance contract, policy, certificate, or other evidence of coverage.
4. (d) When engaged in review to determine the appropriate length of an inpatient hospital stay, no medical utilization review entity shall reduce or recommend a reduction of benefits otherwise payable, based on a determination that a hospital stay is medically unnecessary or inappropriate, unless sufficient notice is given so that the beneficiary is allowed an expedited review.

Source. #5931, eff 12-5-94, EXPIRED: 12-5-00 New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10; ss by #12545, eff 6-11-18