Q. What is Utilization review?

A. Utilization review is defined as a system for reviewing the necessary, appropriate, and efficient allocation of health care resources and services given or proposed to be given to a patient or group of patients. §38.70.10(1)

Q. What is a private review agent?

 A. A private review agent is defined as a person performing utilization reviews who is either under contract with or acting on behalf of, but not employed by: (a) a South Carolina business entity; (b) the State of South Carolina; or (c) a hospital. Section §38.70.10(2)

Q. Who is subject to the state’s utilization review laws?

 A. The law applies to those who perform utilization reviews on behalf of, but are not employed by (a) a South Carolina business entity; (b) the State of South Carolina; or (c) a hospital. What exemptions are provided, if any? Insurance companies, administrators of insurance benefit plans, and health maintenance organizations licensed and regulated by the South Carolina Department are exempt from the certification requirements for private review agents. §38.70.10

HMOs? HMOs licensed and regulated by the Department of Insurance that perform utilization review are not required to obtain a certificate. However, these HMOs must comply with such provisions as procedures for utilization review determinations, appeals process, information upon which utilization review is conducted. SC. Regulations 69-47.

1. Insurers? No
2. Utilization review organizations? Yes.
3. Workers Compensations? No.
4. 4. Retrospective review? Yes.

Q.  Is it required for a private review agent performing utilization review on single-employer, self-insured health plans to obtain a license?

 A.  No. Private review agents performing utilization reviews only for single-employer, self-insured employee health plans are not required to obtain a certificate. SC Regulation 69-47 (H)(2)

Q.  Is the license transferable?

 A.  No utilization review license is transferable. If the business is sold, or transferred, the issued certificate will automatically cancel. The surviving business must apply for a new certificate. §38.70.10(5)

Q.  Where can I find the laws and regulations that govern utilization review and private review agents?

 A.  The laws and regulations that govern utilization review and private review agents are found in Chapter 70 of the SC Code of Laws and SC Regulations 69-47.

Q.  What are the licensing requirements to become licensed as a utilization review and private review agent?

 A.  The licensing requirements are: (1) complete a application packet; (2) licensing fee of $1,200 dollars; (3) file a copy of certificate of authority from home state, letter of good standing, copy of articles of incorporation, (4) provide list(s) of toll free number for accessibility; (5) provide number of incoming telephone lines; (6) provide incoming call queue time; and (7) all materials designed to inform applicable patients of the requirements of the utilization plan.

Q.  How often must licensure be renewed?

 A.  Every two years, beginning on July 1 st of even-numbered year. §38.70.50

Q.  What are the licensure fees (initial and renew)? Application fee of $400. Biennial fee of $800 (renewal).

 A.  The renewal fee is $800 dollars. SC Regulations 69-47 (3)(A)

Q.  When does a utilization review and private review certificate of license expire?

 A.  All certificate of license expire on June 30 th of each even-numbered year. §38.70.50(A)

Q.  Does South Carolina recognize URAC accreditation?

 A.  No.

Q.  Are there any other requirements of utilization review and private review agents?

 A.  Yes. (1) Notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within five business days either by telephone or telecopy facsimile transmission machine. (2) Private review agents must have written procedures to assure that utilization reviews are conducted in a timely manner and for appeals of denials of certification. (3) Private review agents must make a certification determination within two working days of receipt of the necessary information and must make a certification determination of an extended stay or additional service within one working day of receipt of the additional information. Private review agents must not routinely conduct daily review on all such stays. SC Regulations 69-47 (IV) (V)

Q.  Where do you file complaints?

 A.  Complaints are filed with the SC Dept. of Insurance. Complaints should be addressed to the Consumer Service Division.