Ala. Admin. Code r. 480-5-5-.06

Current through Register Vol. 43, No. 1, October 31, 2024

Section 480-5-5-.06 - Utilization Review Entity Qualified To Perform Utilization Review

(1) Technical Reviewer:

(a) It is the express intent of these rules that approval of medical services may be performed by the employer/agent or its designated employee who meets the requirements of Rule 480-5-5-.05. The technical reviewer shall not deny a medical service related to an accepted compensable claim but shall refer any medical services which may not be approved to the first level of clinical review.

(2) First Level Clinical Reviewer:

(a) Nurses and other licensed or similarly certified medical professionals conducting first level clinical review of medical and surgical services and other clinical reviewers conducting reviews shall, in addition to qualifications of Rule 480-5-5-.05:

1. Possess current and valid license or certificate of registration from an appropriate licensure agency;

2. Be familiar with the principles and procedures of utilization review and these rules; and

3. Be clinically supported by an available physician, who has a nonrestricted license to practice medicine.

(3) Second Level Clinical Reviewer:

(a) Physicians or medical directors who directly support the utilization review activity of and employer/agent or RUE shall perform second level clinical review. In addition to the qualifications of Rule 480-5-5-.05, physicians or medical directors performing second level review shall:

1. Hold a current nonrestricted license to practice medicine or a health profession in the United States;

2. Be oriented to the principles and procedures of Utilization review, peer review and these rules;

3. Review cases in which a clinical determination to certify cannot be made by the first level clinical reviewer; and

4. Review all cases in which the utilization review process has concluded that a determination not to certify for clinical reasons is appropriate.

(4) Third Level Clinical Reviewer:

(l) Third level clinical reviewers shall be providers who serve as peer consultants or peer advisors and render Peer Clinical Review (Third Level Clinical Review) determinations for an expedited or standard appeal and shall, in addition to the qualification of Rule 480-5-5-.06(3), demonstrate their competency and currency by:

1. Being in active practice for standard appeal; or

2. Holding a current nonrestricted license to practice medicine or a health profession in the United States for a expedited appeal; and

3. Being board certified in the same or similar specialty approved by the American Board of Medical specialists for Physicians or the Advisory Board of Osteopathic Specialists for Osteopaths from the major areas of clinical services or a physician who normally treats that type of case as the ordering provider, whose medical services are being non-certified or denied, or for nonphysical clinical peers, the recognized professional board for their specialty; and

4. Being familiar with the principles and procedures of utilization review, peer review and these rules.

(5) An entity seeking to become qualified under this Rule shall submit an application in the form approved by the Director of the Department to the Workers' Compensation Division.

(6) Qualified Utilization Review Entity (RUE): A utilization review entity performing utilization review shall have a review staff properly qualified pursuant to the Rule and trained, supervised and supported by written clinical review criteria and review procedures.

(7) Qualifications for a Qualified Utilization Review Entity Certificate:

(a) An applicant for certification shall submit an application to the Workers' Compensation Division and meet the Department's minimal requirements as established by this Rule.

(b) The application shall be WC Form 50, or most current revision.

(c) The Department shall issue a certificate to an applicant that has met all the requirements of this Rule.

(d) Any utilization review entity who is accredited by URIC or the Alabama Department of Public Health shall be deemed to be qualified and shall be issued a certificate by the Department upon receipt of a copy of the entity's URIC or Department of Public Health certification.

(e) A certificate issued to the RUE under this Rule is nontransferable.

(f) A certificate initially issued pursuant to this Rule shall expire two years following its effective date unless renewed for a two-year term pursuant to the Department's requirements for such renewal.

(g) The Department may deny a certificate to any applicant if, upon review of the application the Department determines that the applicant proposing to conduct utilization review, does not at all times comply with the following requirements:

1. Have available the services of a physician licensed to practice medicine who can administer its utilization review activities;

2. Protect the confidentiality of medical records, and be reasonably accessible to injured workers and providers Monday through Friday, except legal holidays, during normal business hours;

3. Make available to providers updated information regarding addresses, telephone numbers, business hours and contact persons for utilization review activities;

4. Provide the statistical data elements as reasonably required by the Department;

5. Maintain policies and procedures to comply with URIC standards and prevailing adjudication rules used in Alabama for situations not specifically addressed in these RULES;

6. Maintain policies and procedures assuring the timely review of appealed or denied services by a physician or other provider board certified in the same or similar specialty of the provider whose services are being denied or (a physician who normally treats the same type of case that is being denied;

7. Maintain policies and procedures assuring a system to properly and promptly review claims. The documentation shall be retrievable on a claim-by-claim basis for completion and classification on activity performance; and

8. Provide a name and telephone number of a person for the Department to contact.

(8) The Department shall notify the RUE in writing of any alleged violation of these Rules.

(a) Delivery of the notice shall be by either certified or registered mail.

(b) The qualified entity shall respond in writing to the notice not later than 30 days after the notice is received.

(c) Before denying or revoking a certificate under this Rule, the Department shall provide the applicant certificate holder with the opportunity to file an administrative appeal pursuant to the Rule 480-5-5-.23(2) and the successive levels of appeal.

Author: Workers' Compensation Medical Services Board

Ala. Admin. Code r. 480-5-5-.06

New Rule: Filed August 9, 1996; effective September 13, 1996.

Statutory Authority:Code of Ala. 1975, § 25-5-293 and 1994 Alabama Act 786.