SB350 Alabama 2013 Session

To repeal portions of Title 27 of the Code of Alabama 1975

Relating to the Alabama Insurance Code, to repeal the following: 27-3A-5 (a) Except as provided in subsection (b), all utilization review agents shall meet the following minimum standards: (1) Notification of a determination by the utilization review agent shall be mailed or otherwise communicated to the provider of record or the enrollee or other appropriate individual within two business days of the receipt of the request for determination and the receipt of all information necessary to complete the review. (2) Any determination by a utilization review agent as to the necessity or appropriateness of an admission, service, or procedure shall be reviewed by a physician or determined in accordance with standards or guidelines approved by a physician. (3) Any notification of determination not to certify an admission, service, or procedure shall include the principal reason for the determination and the procedures to initiate an appeal of the determination. (4) Utilization review agents shall maintain and make available a written description of the appeal procedure by which the enrollee or the provider of record may seek review of a determination by the utilization review agent. The appeal procedure shall provide for the following: a. On appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate shall be made by a physician in the same or a similar general specialty as typically manages the medical condition, procedure, or treatment under discussion as mutually deemed appropriate. A chiropractor must review all cases in which the utilization review organization has concluded that a determination not to certify a chiropractic service or procedure is appropriate and an appeal has been made by the attending chiropractor, enrollee, or designee. b. Utilization review agents shall complete the adjudication of appeals of determinations not to certify admissions, services, and procedures no later than 30 days from the date the appeal is filed and the receipt of all information necessary to complete the appeal. c. When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination over the telephone on an expedited basis. A representative of a hospital or other health care provider or a representative of the enrollee or covered patient may assist in an appeal. Utilization review agents shall complete the adjudication on an expedited basis. Utilization review agents shall complete the adjudication of expedited appeals within 48 hours of the date the appeal is filed and the receipt of all information necessary to complete the appeal. Expedited appeals that do not resolve a difference of opinion may be resubmitted through the standard appeal process. (5) Utilization review agents shall make staff available by toll-free telephone at least 40 hours per week during normal business hours. (6) Utilization review agents shall have a telephone system capable of accepting or recording incoming telephone calls during other than normal business hours and shall respond to these calls within two working days. (7) Utilization review agents shall comply with all applicable laws to protect the confidentiality of individual medical records. (8) Physicians, chiropractors, or psychologists making utilization review determinations shall have current licenses from a state licensing agency in the United States. (9) Utilization review agents shall allow a minimum of 24 hours after an emergency admission, service, or procedure for an enrollee or representative of the enrollee to notify the utilization review agent and request certification or continuing treatment for that condition. (b) Any utilization review agent that has received accreditation by the utilization review accreditation commission shall be exempt from this section. 27-3A-6 (a) Whenever the department has reason to believe that a utilization review agent subject to this chapter has been or is engaged in conduct that violates this chapter, the department shall notify the utilization review agent of the alleged violation. The agent shall respond to the notice not later than 30 days after the notice is made. (b) If the department finds that the utilization review agent has violated this chapter, or that the alleged violation has not been corrected, the department may conduct a contested case hearing on the alleged violation in accordance with the Administrative Procedure Act. (c) If, after the hearing, the department determines that the utilization review agent has engaged in a violation, the department shall reduce the findings to writing and shall issue and cause to be served upon the agent a copy of the findings and an order requiring the agent to cease and desist from engaging in the violation. (d) The department may also exercise either or both of the following disciplinary powers: (1) Impose an administrative fine of not more than five thousand dollars ($5,000) for a violation that occurred with such frequency as to indicate a general business pattern or practice. (2) Suspend or revoke the certification of a utilization review agent if the agent knew the act was in violation of this chapter and repeated the act with such frequency as to indicate a general business pattern or practice. 27-4-2 (a) The Commissioner of Insurance shall collect in advance fees, licenses, and miscellaneous charges as follows: (1) Certificate of authority: a. Initial application for original certificate of authority, including the filing with the commissioner of all documents incidental thereto ..... $500 b. Issuance of original certificate of authority ..... 500 c. Annual continuation or renewal fee ..... 500 d. Reinstatement fee ..... 500 (2) Charter documents, filing with the commissioner amendment to articles of incorporation or of association, or of other charter documents or to bylaws ..... 25 (3) Solicitation permit, filing application and issuance ..... 250 (4) Annual statement of insurer, except when filed as part of application for original certificate of authority, filing ..... 25 (5) Producer licenses (resident or nonresident): a. Individuals: 1. Application fee (For filing of initial application for license) ..... 20 2. License fee (For issuance of original license) ..... 40 b. Business entities: 1. Application fee (For filing of initial application for license) ..... 20 2. License fee (For original license and each biennial renewal) ..... 100 c. Examination fees (For producer examination or reexamination, each classification of examination) ..... 50 (6) Producer appointment fee: a. Filing notice of appointment ..... 30 b. Annual continuation of appointment ..... 10 (7) Reinsurance intermediary license: a. Filing application for