33-32-210. (Effective January 1, 2026) Qualifications of individuals making or reviewing adverse determinations.
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33-32-210 . (Effective January 1, 2026) Qualifications of individuals making or reviewing adverse determinations.
(1)A health insurance issuer or its utilization review organization shall ensure that all adverse determinations pursuant to 33-32-211 or 33-32-212 are made by:
(a)a physician when the request is by or on behalf of a physician; or
(b)a health care professional licensed in the same profession as the health care professional making the request, or, in any case, by a physician.
(2)A physician or other health care professional making an adverse determination pursuant to subsection
(1)must:
(a)possess a current and valid nonrestricted license; and
(b)have experience treating and managing patients with the medical condition or disease for which the health care service is being requested, or shall refer the review to a physician with the requisite specialized knowledge and experience.
(3)A health insurance issuer or its utilization review organization shall ensure that only a physician reviews a grievance as provided under 33-32-308 or 33-32-309 . A physician making an adverse determination or reviewing a grievance must:
(a)possess a current and valid nonrestricted license to practice medicine; and
(b)be of a specialty that focuses on the diagnosis and treatment of the condition that is being treated.
(4)A health insurance issuer or its utilization review organization must make all adverse determinations under the clinical direction of one of the utilization review organization's medical directors who is responsible for the oversight of the utilization review activities for covered persons in the state. A medical director used for this purpose must be a licensed physician.
(5)For the purposes of this section, "adverse determination" has the same meaning as provided in 33-32-102 (1)(a) or (1)(c).