Written criteria concerning coverage of health care services and standards for quality of health care services.
1. Each managed care organization shall establish written criteria:
(a) Setting forth the manner in which it determines whether to authorize coverage of a health care service; and
(b) Setting forth its method for reviewing standards for the quality of health care services provided to an insured.
2. Such written criteria must be:
(a) Developed with the assistance of practicing providers of health care;
(b) Developed using generally recognized and, if appropriate, specialized clinical principles and processes;
(c) Reviewed at least one time each year and, if appropriate, updated; and
(d) Made available to an insured for review upon request of the insured any time that the managed care organization denies coverage of a specific health care service to the insured.
Last modified: February 27, 2006