N.H. Admin. Code § Ins 2001.07

Current through Register No. 50, December 12, 2024

Section Ins 2001.07 - Forms Required

(a) The applicant for a medical utilization review license or for the renewal of such license shall provide the following on Form INS-MURL-APP-1 Application for License as a Medical Utilization Review Facility:

(1) The exact name of the utilization review entity for which application is made;

(2) The applicant's Federal I.D. number or Social Security number;

(3) A statement as to whether the application is for a new license or for renewal of a license;

(4) The applicant's current street address and mailing address, if different;

(5) The name and address of the parent company if the applicant is a subsidiary;

(6) The name and address of the medical director;

(7) Verification that the medical director is licensed under RSA 329;

(8) A statement as to whether the applicant is a partnership, corporation, or association, or other type of organization such that:

a. If the applicant is a corporation, it shall indicate the state of incorporation and list all states in which the corporation does business; and

b. If the applicant represents a type of organization other than a partnership, corporation, or association, it shall specify its type of organization;

(9) A list of the principal proprietors, partners, directors, officers, and administrators and any others responsible for the operation, management, and control of the applicant;

(10) A biographical sketch of all principal proprietors, partners, directors, officers, and administrators listed which shall include, at a minimum, the person's current business and home address, current position(s), education, and previous experience;

(11) A statement showing the number of the applicant's employees in New Hampshire and the estimated number of employees nationally;

(12) If operations are conducted at more than one location, whether in or outside of New Hampshire, a list of all locations, the range of activities at each location, and the number of employees at each location;

(13) A description of the types of medical utilization review programs offered by the applicant, including but not limited to:

a. Second opinion program;

b. Hospital preadmission review;

c. Preinpatient service eligibility certification; and

d. Concurrent review to determine appropriate length of a hospital stay;

(14) A description of the process by which the applicant performs each of the medical utilization review services listed pursuant to the requirement of Ins 2001.07(a)(13) and shall specify:

a. The steps followed by the applicant's personnel in the performance of each type of review program; and

b. The categories of health care personnel that perform medical utilization review for the applicant and whether those persons are licensed in this or any other state;

(15) A description of the process used by the applicant to address beneficiary and provider complaints, requests for redeterminations, and appeals;

(16) A copy of all materials to be used by the applicant to inform beneficiaries of the requirements of the utilization review plans and the rights and responsibilities of the beneficiaries under the plan;

(17) A statement of whether the applicant's utilization review program has been certified by either the Utilization Review Accreditation Commissioner (URAC) or the National Committee for Quality Assurance (NCQA);

(18) A statement of the telephone number or numbers, including any toll-free numbers and fax numbers, at which beneficiaries and providers may reach representatives of the applicant including:

a. The number of lines maintained;

b. The hours and days of the week during which representatives of the applicant may be contacted; and

c. Any hours or days of the week during which calls are unanswered or are answered solely by recordings or answering services which do not provide access to representatives during the call;

(19) A statement by the applicant describing the procedures established for preserving the confidentiality of medical information used in the utilization review process, including a signed acknowledgment that the applicant shall sign stating that, "The undersigned also acknowledges that all applicable state and federal laws to protect the confidentiality of medical information will be followed."; and

(20) The signature of the applicant, or an officer of the firm if the applicant is a firm, certifying the following statement: "I have read the foregoing application and attachments and state that the answers supplied therein are true and correct to the best of my knowledge and belief. Further, by submitting this application to the insurance department, the applicant acknowledges that it has read and will comply with the performance standards set forth in RSA 420-E and any applicable rules."

(b) If the purpose of the application is to renew a license, the applicant shall, in the course of providing the information required by Ins 2001.07(a)(4) through (20), explain any changes from the most recent previous application on file with the department.

N.H. Admin. Code § Ins 2001.07

#5931, eff 12-5-94, EXPIRED: 12-5-00

New. #7683, eff 6-1-02; ss by #9721-B, eff 6-11-10

Amended by Volume XXXVIII Number 28, Filed July 12, 2018, Proposed by #12545, Effective 6/11/2018, Expires 6/11/2028.