P.R. Laws tit. 26, § 9427
(a)
(1) A health insurance organization or issuer that requires a request for benefits under the covered person or enrollee’s health plan to be subjected to utilization review shall implement a written utilization review program that describes all review activities and procedures, both delegated and non-delegated for:
(A) The procedure to file benefit requests;
(B) the notification of utilization review and benefit determinations, and
(C) the adverse determinations review process in accordance with §§ 9391–9400 of this title.
(2) The program document shall describe the following:
(A) Procedures to evaluate the medical necessity, appropriateness, efficacy or efficiency of healthcare services;
(B) data sources and clinical review criteria used in decision-making process;
(C) mechanisms to ensure consistent application of clinical review criteria and compatible decisions;
(D) data collection processes and analytical methods used in assessing utilization of healthcare services;
(E) provisions for assuring confidentiality of clinical and proprietary information;
(F) the organizational structure (e.g. utilization review committee, quality assurance or other committee) that periodically assesses utilization review activities and reports to the health insurance organization or issuer’s governing body, and
(G) the position of the staff functionally responsible for day- to-day program management.
(b)
(1) Health insurance organizations or issuers shall file with the Commissioner, in the prescribed format, an annual report summarizing the activities of the utilization review program.
(2)
(A) In addition to the annual report summarizing the activities of the utilization review program, health insurance organizations or issuers shall keep, for a period of not less than six (6) years, records of all requests for benefits and claims and notifications related to the utilization review process.
(B) Health insurance organizations or issuers shall make the records mentioned in paragraph (A) of this clause available upon request to the Commissioner and any other regulatory agency.
History —Aug. 29, 2011, No. 194, added as § 24.070 on Aug. 23, 2012, No. 203, § 5, eff. 90 days Aug. 23, 2012.