(a) (1) Every health insurance plan proposing to issue or deliver a health insurance policy or contract or administer a health benefit program which provides for the coverage of hospital and medical benefits and the utilization review of those benefits shall:
(A) Have a certificate in accordance with this subchapter; or
(B) Contract with a private review agent who has a certificate in accordance with this subchapter.
(2) Notwithstanding any other provisions of this subchapter, for claims in which the medical necessity of the provision of a covered benefit is disputed, a health service plan that does not meet the requirements of this subsection shall pay any person or hospital entitled to reimbursement under the policy or contract.
(b) (1) Every insurer proposing to issue or deliver a health insurance policy or contract or administer a health benefit program which provides for the coverage of hospital and medical benefits and the utilization review of such benefits shall:
(A) Have a certificate in accordance with this subchapter; or
(B) Contract with a private review agent that has a certificate in accordance with this subchapter.
(2) Notwithstanding any provision of this subchapter, for claims in which the medical necessity of the provision of a covered benefit is disputed, an insurer that does not meet the requirements of this subsection shall pay any person or hospital entitled to reimbursement under the policy or contract.
(c) (1) Any health insurer proposing to issue or deliver in this state a group or blanket health insurance policy or administer a health benefit program which provides for the coverage of hospital and medical benefits and the utilization review of such benefits shall:
(A) Have a certificate in accordance with this subchapter; or
(B) Contract with a private review agent that has a certificate in accordance with this subchapter.
(2) Notwithstanding any provision of this subchapter, for claims in which the medical necessity of the provision of a covered benefit is disputed, a health insurer that does not meet the requirements of this subsection shall pay any person or hospital entitled to reimbursement under the policy or contract.
Section: Previous 20-9-902 20-9-903 20-9-904 20-9-905 20-9-906 20-9-907 20-9-908 20-9-909 20-9-910 20-9-911 20-9-912 20-9-913 20-9-914 NextLast modified: November 15, 2016