SECTION 310:657-7-2. Scope and content of utilization review

(a)   The Plan shall implement a utilization review program that describes all delegated and nondelegated review activities for covered services. The program shall include:

(1)   Procedures to evaluate service need, appropriateness and efficiency, with processes to detect service underuse and overuse;

(2)   Data sources and review criteria used to determine the need for, and appropriateness of, medical and health services;

(3)   Processes for resolving disputes on medical or health services;

(4)   Consistent application of criteria and decisions;

(5)   Data collection and analytical methods that may be used to assess use of health care services;

(6)   Provisions for ensuring confidentiality of information;

(7)   Reports to the governing body or its designee; and

(8)   Day-to-day program management.

(b)   The Plan shall file with the Commissioner an annual report summarizing utilization review activities. The data shall preserve the confidentiality of information about individual workers. The Commissioner may request additional information based on material in the report.

[Source: Added at 12 Ok Reg 2977, eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96]