Section 991.2152 - Operational standards(a) A utilization review entity shall do all of the following: (1) Respond to inquiries relating to utilization review determinations by: (i) providing toll-free telephone access at least forty (40) hours per week during normal business hours;(ii) maintaining a telephone answering service or recording system during nonbusiness hours; and(iii) responding to each telephone call received by the answering service or recording system regarding a utilization review determination within one (1) business day of the receipt of the call.(2) Protect the confidentiality of enrollee medical records as set forth in section 2131.(3) Ensure that a health care provider is able to verify that an individual requesting information on behalf of the managed care plan is a legitimate representative of the plan.(4) Conduct utilization reviews based on the medical necessity and appropriateness of the health care service being reviewed and provide notification within the following time frames: (i) A prospective utilization review decision shall be communicated within two (2) business days of the receipt of all supporting information reasonably necessary to complete the review.(ii) A concurrent utilization review decision shall be communicated within one (1) business day of the receipt of all supporting information reasonably necessary to complete the review.(iii) A retrospective utilization review decision shall be communicated within thirty (30) days of the receipt of all supporting information reasonably necessary to complete the review.(5) Ensure that personnel conducting a utilization review have current licenses in good standing or other required credentials, without restrictions, from the appropriate agency.(6) Provide all decisions in writing to include the basis and clinical rationale for the decision.(7) Notify the health care provider of additional facts or documents required to complete the utilization review within forty-eight (48) hours of receipt of the request for review.(8) Maintain a written record of utilization review decisions adverse to enrollees for not less than three (3) years, including a detailed justification and all required notifications to the health care provider and the enrollee.(b) Compensation to any person or entity performing utilization review may not contain incentives, direct or indirect, for the person or entity to approve or deny payment for the delivery of any health care service.(c) Utilization review that results in a denial of payment for a health care service shall be made by a licensed physician, except as provided in subsection (d).(d) A licensed psychologist may perform a utilization review for behavioral health care services within the psychologist's scope of practice if the psychologist's clinical experience provides sufficient experience to review that specific behavioral health care service. The use of a licensed psychologist to perform a utilization review of a behavioral health care service shall be approved by the department as part of the certification process under section 2151. A licensed psychologist shall not review the denial of payment for a health care service involving inpatient care or a prescription drug.1921, May 17, P.L. 682, No. 284, § 2152, added 1998, June 17, P.L. 464, No. 68, § 1, effective 1/1/1999.