Download CHAPTER 59A-15

CHAPTER 59A-15
PRIVATE UTILIZATION REVIEW
59A-15.002
59A-15.004
59A-15.009
Definitions
Registration Requirements
Confidentiality
59A-15.002 Definitions.
When used in this part, unless the context requires otherwise, the term:
(1) “AHCA” means the Agency for Health Care Administration.
(2) “Description of policies and procedures” means a narrative summarizing the matter to be described, but does not require the
submission of actual or facsimile documents or procedures or proprietary information or trade secrets.
(3) “Initial denial determination” means a determination by a private review agent that the health care services furnished or
proposed to be furnished to a patient are inappropriate, not medically necessary, or not reasonable.
(4) “Licensed practical nurse” is a person who holds a current active license to practice nursing.
(5) “Physician” is a person who holds a current active license to practice medicine.
(6) “Private review agent” means any person or entity which performs utilization review services for third-party payors on a
contractual basis for outpatient or inpatient services. However, the term shall not include full-time employees, personnel, or staff of
health care insurers, health maintenance organizations, or hospitals, or wholly owned subsidiaries thereof or affiliates under common
ownership, when performing utilization review for their respective hospitals, health maintenance organizations, or insureds of the
same insurance group. For this purpose, health insurers, health maintenance organizations, and hospitals, or wholly owned
subsidiaries thereof or affiliates under common ownership, include such entities engaged as administrators of self-insurance as
defined in Section 624.031, F.S.
(7) “Reconsideration” is an initial written request, prior to a final determination, for additional review of a private review
agent’s determination not to certify an admission, extension of stay, or other medical service.
(8) “Registered nurse” is a person who holds a current active license to practice nursing.
(9) “Utilization review” means a system for reviewing the medical necessity or appropriateness in the allocation of health care
resources of hospital services given or proposed to be given to a patient or group of patients.
(10) “Utilization review plan” means a description of the policies and procedures governing utilization review activities
performed by a private review agent.
Specific Authority 395.037 FS. Law Implemented 395.0172 FS. History–New 2-18-92, Formerly 10D-111.002.
59A-15.004 Registration Requirements.
In addition to requirements set forth in Section 395.0199, F.S., an application for registration shall be accompanied by the following
supporting documentation:
(1) A utilization review plan which shall include a description of policies and procedures governing the types of utilization review
activities performed, that shall include one or more of the following types of utilization review:
(a) Preadmission;
(b) Admission;
(c) Preauthorization;
(d) Discharge planning;
(e) Concurrent review;
(f) Retrospective review; or
(g) Readmission review.
When a private utilization review agent applies different policies and procedures to different types of utilization review, the different
types of review shall be defined and a description of the policies and procedures applicable to each different type shall be provided.
(2) A description of policies and procedures governing utilization review activities including:
(a) Formats completed during the review;
(b) Timetables that shall be met during the review; and
(c) A written protocol describing the review;
(3) A description of the policies and procedures by which patients, physicians, or hospitals may seek reconsideration or appeal
of adverse decisions by the private review agent including:
(a) Formats completed during the reconsideration process;
(b) Timetables that shall be met during the reconsideration process;
(c) A written protocol describing how the adverse decision shall be appealed; and
(d) A review by the appropriate licensed physician or by the appropriate licensed physician practicing in the field of psychiatry
for review of mental health services, that shall include the name of the physician, and a written and dated evaluation and findings of
the reviewing physician, including the principal reason(s) for the adverse decision.
Specific Authority 395.1055 FS. Law Implemented 395.0199 FS. History–New 2-18-92, Formerly 10D-111.004, Amended 3-18-96.
59A-15.009 Confidentiality.
Private review agents shall develop written policies and procedures to ensure that confidentiality of personal and medical record
information is protected.
Specific Authority 395.037 FS. Law Implemented 395.0172 FS. History–New 2-18-92, Formerly 10D-111.009.