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Utilization Review Agent

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.

Insurers

  • Licensing/Registration
    • Acquisition and Holding Company Registration
    • Captive Insurer/Domestic RRG
    • Insurer
    • Life Care Provider
    • Life Settlement Provider
    • Premium Finance Company
    • Purchasing Group
    • Rate Service Organization
    • Rating Organization
    • Reinsurer
    • Risk Retention Group - Domestic (Captive Insurer)
    • Risk Retention Group - Foreign
    • Senior Residential Entrance Fee Contract Provider
    • Service Company
    • Surplus Lines Insurer
    • Third Party Administrator (Life/Health)
    • Utilization Review Agent
  • Trust Deposits
  • Financial Reporting for Domestic Entities
    • Acquisition/Holding Company Registration
    • Captive Insurer
    • Health Care Services Organization
    • HMDO Service Corporation
    • Life & Disability Reinsurer
    • Life Care Provider
    • Life/Disability Insurer Filing on a Health Blank
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    • Mechanical Reimbursement Reinsurer
    • Mortgage Guaranty Insurer
    • Prepaid Dental Plan Organization
    • Property/Casualty Insurer Filing on a Health Blank
    • Property/Casualty Insurer Not Filing on a Health Blank
    • Risk Retention Group
    • Title Insurer
    • Senior Residential Entrance Fee Contract Provider
    • Unaffiliated Credit Life & Disability Reinsurer
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    • Fraternal Benefit Society
    • Health Care Services Organization
    • Life Care Provider
    • Life/Disability Insurer Filing on a Health Form
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    • Mortgage Guaranty Insurer
    • Mutual Aid Association
    • Prepaid Legal Insurer
    • Property/Casualty Insurer Filing on a Health Blank
    • Property/Casualty Insurer Not Filing on a Health Blank
    • Reinsurer
    • Risk Retention Group
    • Title Insurer
  • Life & Health Rates, Forms & Compliance
    • Health Care Appeals
    • Life/Health/Annuity Form Filing Requirements
    • Life/Health/Annuity Advertising Filing Requirements
    • Life/Health/Annuity Rate Filing Requirements
    • Long-term Care
    • Credit Insurance
    • Life Settlement Provider
    • Health Plans Survey (Annual)
    • HIPAA Data Reporting
    • Market Conduct Exam Reports
  • Property & Casualty Rates, Forms & Compliance
    • P&C Rate & Form Filing Requirements
    • Examinations and Analysis Program
    • Market Conduct Exam Reports
    • Motor Vehicle Non-renewals Report
  • Laws, Rules and Bulletins
    • Laws and Rules
    • Rules & Rulemaking
    • Regulatory Bulletins
  • Insurance Fraud
  • Taxes
  • File a Health Care Appeal

Contact Info

Life and Health Section

100 N. 15th Avenue, Suite 261
Phoenix, AZ 85007-2630
[email protected]
602-364-2393
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