48.165.045  <<  48.165.050 >>   End of Chapter

Lead organization tasksDevelop and promote uniform practicesMedical management protocols.

(1) By December 31, 2010, the lead organization shall:
(a) Develop and promote widespread adoption by payors and providers of guidelines to:
(i) Ensure payors do not automatically deny claims for services when extenuating circumstances make it impossible for the provider to: (A) Obtain a preauthorization before services are performed; or (B) notify a payor within twenty-four hours of a patient's admission; and
(ii) Require payors to use common and consistent time frames when responding to provider requests for medical management approvals. Whenever possible, such time frames shall be consistent with those established by leading national organizations and be based upon the acuity of the patient's need for care or treatment;
(b) Develop, maintain, and promote widespread adoption of a single common website where providers can obtain payors' preauthorization, benefits advisory, and preadmission requirements;
(c) Establish guidelines for payors to develop and maintain a website that providers can employ to:
(i) Request a preauthorization, including a prospective clinical necessity review;
(ii) Receive an authorization number; and
(iii) Transmit an admission notification.
(2) By October 31, 2010, the lead organization shall propose to the commissioner a set of goals and work plan for the development of medical management protocols, including whether to develop evidence-based medical management practices addressing specific clinical conditions and make its recommendation to the commissioner, who shall report the lead organization's findings and recommendations to the legislature.
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