As Amended
SEC. 41-83-31. Adverse determination to patient or health care provider; denial of third party reimbursement; denial of pre-certification for particular service; evaluation by trained specialist.
Any program of utilization review with regard to hospital, medical or other health care services provided in this state shall comply with the following:
(a) No determination adverse to a patient or to any affected health care provider shall be made on any question relating to the necessity or justification for any form of hospital, medical or other health care services without prior evaluation and concurrence in the adverse determination by a physician. The reasons for any adverse determination shall be discussed by said physician with the affected health care provider, if the provider so requests.
(b) Any determination regarding hospital, medical or other health care services rendered or to be rendered to a patient which may result in a denial of third party reimbursement or a denial of pre-certification for that service shall include the evaluation, findings and concurrence of a physician trained in the relevant specialty or subspecialty, if requested by the patient's physician, to make a final determination that care rendered or to be rendered was, is, or may be medically inappropriate.
SOURCES: Laws, 1990, ch. 347, Sec. 16, eff from and after July 1, 1990.