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The "Utilization Review Guide" is a 51-state compilation of statutes and regulations addressing the relationship of utilization or private review agents with health care providers, enrollees, health insurers, and state regulators, such as the insurance, public health, and workers’ compensation departments.

The guide addresses the following topics:

• Utilization Review Agent Duties • Application/Certification Requirements • Grounds for Certification Denials • Notice of Change Requirements • Recordkeeping and Reporting Requirements • Renewal Requirements • Confidentiality Requirements • Complaints • Exemption Criteria • Prohibitions • Waivers • Deadlines • Penalties • Appeal Procedures

The guide also includes hyperlinks to more than 100 utilization review forms. 

To learn more or see sample pages, click here.