RSA 420-J:6 · Utilization Review

420-J:6 Utilization Review. –

Copy link

I.

Written standards and procedures.

Copy link

(a)

Each health carrier conducting utilization review directly or indirectly through a contracted utilization review entity shall have written procedures for carrying out its utilization review processes and shall file such procedures with the commissioner on or before April 1 of each year. Health carriers shall conform to the standards of either the Utilization Review Accreditation Commission or the National Committee for Quality Assurances and are subject to all applicable rules issued pursuant to RSA 420-E:7.

Copy link

(b)

The written procedures shall describe the categories of health care personnel that perform utilization review activities and whether or not such individuals are licensed in this state, and shall address at a minimum: prior authorization requirements; second opinion programs; pre-hospital admission certification; pre-inpatient service eligibility certification; and concurrent hospital review to determine appropriate length of stay; as well as the process used by the health carrier to preserve confidentiality of medical information.

Copy link

(c)

The clinical review criteria used by a health carrier or its contracted utilization review entity shall be in writing and:

Copy link

(1)

Developed with input from appropriate actively practicing practitioners in the health carrier's service area;

Copy link

(2)

Updated at least biennially and as new treatments, applications, and technologies emerge;

Copy link

(3)

Developed in accordance with the standards of national accreditation entities;

Copy link

(4)

Based on current, nationally accepted standards of medical practice; and

Copy link

(5)

If practicable, evidence-based.

Copy link

(d)

All contracts that health carriers make with a utilization review entity shall be available to the commissioner upon request.

Copy link

II.

Disclosure of prior authorization requirements and publication of prior authorization performance indicators.

Copy link

(a)

A health carrier conducting utilization review directly, or indirectly through a contracted utilization review entity, shall make any current prior authorization requirements and restrictions readily accessible on its website to enrollees, health care professionals, and the general public. This includes the written clinical criteria. Requirements shall be described in detail, but also in easily understandable language.

Copy link

(b)

If a health carrier or its contracted utilization review entity intends either to implement a new prior authorization requirement or restriction, or amend an existing requirement or restriction, the health carrier shall:

Copy link

(1)

Ensure that the new or amended requirement is not implemented unless the health carrier's website has been updated to reflect the new or amended requirement or restriction.

Copy link

(2)

Provide contracted health care providers of enrollees written notice of the new or amended requirement or amendment no less than 60 days before the requirement or restriction is implemented.

Copy link

(c)

Effective March 31, 2026, health carriers conducting utilization review directly, or indirectly through a contracted utilization review entity, shall make prior authorization metrics as specified in 45 C.F.R section 156.223 available to the commissioner, and the commissioner shall display relevant corresponding data, in a carrier specific format, on a website maintained by the insurance department in a readily accessible format.

Copy link

III.

Qualifications of reviewers making medical necessity determinations. A health carrier conducting utilization review directly, or indirectly through a contracted utilization review entity, shall ensure that all medical necessity determinations are made by a qualified health care provider. A reviewing provider shall:

Copy link

(a)

Have appropriate medical and professional expertise and credentials to competently apply the health carrier's clinical review criteria.

Copy link

(b)

Make the medical necessity determination under the clinical direction of one of the health carrier's own medical directors or one of the contracted utilization review entity's medical directors who is responsible for the review of health care services provided to covered persons who are residents of New Hampshire.

Copy link

IV.

Medical directors. Each health carrier that conducts utilization review shall employ one or more medical directors who shall have responsibility for all utilization review techniques and methods and their administration and implementation and who shall be licensed in New Hampshire under RSA 329. Nothing in this section shall be construed to preclude a medical director from consulting with or relying on the advice of a physician licensed in this state or any other state. Nothing in this section shall be construed as creating any civil liability to the medical director for the medical director's alleged negligent performance of the aforementioned responsibilities for utilization review.

Copy link

V.

Timeliness standards for processing prior authorization requests submitted electronically. Health carriers conducting utilization review directly, or indirectly through a contracted utilization review entity, shall meet the following time frames for prior authorization determinations requested by participating providers or facilities that submit the prior authorization request through an electronic prior authorization process as designated by the health carrier:

Copy link

(a)

In non-urgent circumstances, health carriers requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination within 7 calendar days of obtaining all information necessary to make the determination. Any request that the health carrier makes for additional information necessary to make the determination shall be made within 7 calendar days of the prior authorization request date.

Copy link

(b)

In urgent circumstances, health carriers requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination as expeditiously as the covered person's medical condition requires, and not later than 72 hours after obtaining all information necessary to make the determination. Any request that the health carrier makes for additional information necessary to make the determination shall be made as expeditiously as required to meet the 72-hour timeline, assuming a timely response from the treating provider.

Copy link

VI.

Timeliness standards for processing prior authorization requests submitted non-electronically. Health carriers conducting utilization review directly, or indirectly through a contracted utilization review entity, shall meet the following time frames for prior authorization determinations requested by participating providers or facilities that submit the prior authorization request through a non-electronic prior authorization process:

Copy link

(a)

In non-urgent circumstances, health carriers requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination within 14 calendar days of obtaining all information necessary to make the determination. Any request that the health carrier makes for additional information necessary to make the determination shall be made within 7 calendar days of the prior authorization request date.

Copy link

(b)

In urgent circumstances, health carriers requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination as expeditiously as the covered person's medical condition requires, and not later than 72 hours after obtaining all information necessary to make the determination. Any request that the health carrier makes for additional information necessary to make the determination shall be made as expeditiously as required to meet the 72-hour timeline, assuming a timely response from the treating provider.

Copy link

VII.

In paragraphs V and VI, "all information necessary to make the determination" shall include any information that may have been provided through a peer-to-peer review.

Copy link

VIII.

A prior authorization request shall be considered approved if the health carrier fails to notify the covered person and the covered person's health care provider of the prior authorization determination within the timeliness standards for making a determination after obtaining all necessary information.

Copy link

IX.

Duration of an approval of a prior authorization request.

Copy link

(a)

Health carriers conducting utilization review directly, or indirectly through a contracted utilization review entity, shall not revoke, limit, condition, or restrict a prior authorization if care is provided within 60 business days from the date the health care provider received approval of the prior authorization request.

Copy link

(b)

A health carrier conducting utilization review directly, or indirectly through a contracted utilization review entity, shall pay a participating health care provider at the contracted payment rate for a health care service provided by the health care provider pursuant to a prior authorization determination that coverage is available unless:

Copy link

(1)

The health care provider materially misrepresented the health care service in the prior authorization request;

Copy link

(2)

The health care service was no longer a covered benefit on the day it was provided;

Copy link

(3)

The health care provider was no longer contracted with the covered person's health carrier on the date the care was provided;

Copy link

(4)

The health care provider failed to meet the health carrier's timely filing requirements;

Copy link

(5)

The patient was no longer eligible for health care coverage on the day the care was provided; or

Copy link

(6)

The health carrier does not have liability for the claim or for a part of the claim for any reason under the covered person's coverage policy, the provider contract between the health carrier and the participating provider, or any other reason applicable at law or in equity.

Copy link

X.

Option to request a peer-to-peer review. When a health carrier requires prior authorization for an item or service, the carrier shall offer the provider the opportunity to request a peer-to-peer review of a prior authorization request in which the provider is able to have a direct conversational exchange with a medical director or a designated provider who is a clinical peer about the basis for the prior authorization request. A "clinical peer" in this context shall be a health care professional who has demonstrable expertise to review a case, whether or not the reviewing professional is in the same or a similar specialty as the provider. The peer-to-peer review may be requested before the carrier's prior authorization determination or after a prior authorization denial and before a formal grievance request has been made. The peer-to-peer review shall be made available by the health carrier within 2 business days of the request. If the peer-to-peer review is requested after a prior authorization denial, the heath carrier shall treat the review request as a request for reconsideration that is external to the grievance process and shall provide the provider and the covered person a written determination containing a statement of the specific reasons for the reconsideration determination with reference to the information provided in the peer-to-peer review. The written reconsideration determination shall be provided within 7 business days of the peer-to-peer review.

Copy link

XI.

Nothing in this section shall be construed to contravene a covered person's right to external review under RSA 420-J:5-a. Unless otherwise required by law, the prior authorization requirements set out in this chapter shall apply to all medical services and items. Source. 1997, 345:1. 2000, 18:5, 15. 2001, 207:13. 2003, 276:11, eff. July 1, 2003. 2024, 172:5, eff. Jan. 1, 2025.

Copy link