Arizona Department of Insurance

Utilization Review Agent

Mon, 12/15/2014 - 14:44
Tue, 09/10/2019 - 14:27

Warning - Phishing Scam

We are aware of a phishing scam targeting insurance professionals claiming that the National Association of Insurance Commissioners received a complaint that the professional submitted a falsified claim. This fraudulent email displays the NAIC and CIPR logos, can originate from what appears to be an naic.org or gmail.com email account, and instructs the recipient to click on a link to download the complaint notification.

Certain antivirus products will detect this as a malicious email.  If you receive a similar email and have any concerns, contact the NAIC Service Desk at (816) 783-8500 or [email protected].

WHAT IS A UTILIZATION REVIEW AGENT

A utilization review agent (URA), defined in ARS § 20-2501, determines the medical necessity and appropriateness of health care services.

WHO MUST BE REGISTERED?

A URA must register with the Arizona Department of Insurance to perform utilization review for fully insured commercial business.  Government coverage, such as Medicare or Medicaid are not insurance products regulated by the Department of Insurance under Title 20.  Therefore, registration is not required to perform utilization review for Medicare and Medicaid.

Other entities exempt from Arizona Department of Insurance URA registration requirements are: 

  • An entity that only conducts internal utilization review for hospitals, home health agencies, clinics, private offices, or other health-provider facilities if the review does not result in a decision to approve or deny payment for hospital or medical services.  ARS § 20-2502(B)(2).
  • An entity that only conducts utilization review activities for work related injuries and illnesses covered under the workers’ compensation laws in ARS Title 23.  ARS § 20-2502(B)(3).
  • An entity that only conducts utilization review activities for a self-funded or self-insured employee benefit plan if the regulation of that plan is preempted by Section 514(b) of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 USC § 1144(b). ARS § 20-2502(B)(4).

REGISTRATION REQUIREMENTS

Please contact the Life and Health Division at (602) 364-2393 for details on how to become registered in Arizona to perform utilization review for fully insured commercial business.

ARS § 41-1030(G) requires most Arizona government agencies to prominently print the provisions of ARS § 41-1030(B), (D), (E) and (F) on all license applications.  The following is the language in ARS § 41-1030(B), (D), (E) and (F):

B.        An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.

D.        This section may be enforced in a private civil action and relief may be awarded against the state.  The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.

E.        A state employee may not intentionally or knowingly violate this section.  A violation of this section is cause for disciplinary action or dismissal pursuant to the agency’s adopted personnel policy.

F.         This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.