Revised Statutes of the State of New Hampshire §420-E:4

“Minimum standards; licensure of medical utilization review entities under the insurance law”

All licensed medical utilization review entities must establish a utilization review procedure by which a claimant may seek a claim benefit determination. Medical utilization review entities must maintain a toll-free telephone number to ensure that a representative must be accessible by telephone to insureds, patients, and providers 7 days a week during normal working hours. Claim benefit determinations must be made by a licensed or certified health care provider.

Clinical review criteria considered or utilized in making claim benefit determinations must be: developed with input from appropriate actively practicing practitioners in the carrier or other licensed entity's service area; updated at least biennially; developed in accordance with the standards of national accreditation entities: based on current, nationally accepted standards of medical practice; and evidence-based.

The determination of a claim involving urgent care must be made within 72 hours.

The determination of a claim involving urgent care and relating to the extension of an ongoing course of treatment and involving a question of medical necessity must be made within 24 hours.

The determination of all other claims for pre-service and post-service benefits must be made within 15 days.

Related laws:

Revised Statutes of the State of New Hampshire §404-G:5-f

Revised Statutes of the State of New Hampshire §420-E:6

Revised Statutes of the State of New Hampshire §420-E:7