31.10.21.05

.05 Patient Referrals by Private Review Agents.

A. Except as provided in §B of this regulation, this regulation does not apply to:

(1) A private review agent referring an individual to a health care provider or facility that participates in a health maintenance organization;

(2) A preferred provider organization network of participating health care providers or facilities to which the individual would otherwise be referred as part of the individual's membership or insurance contract; or

(3) An employee assistance program referring an individual to a network of participating health care providers or facilities in accordance with a contract with the individual's employer or labor union to provide comprehensive mental health and substance abuse services.

B. A private review agent or other individual who is affiliated with, under contract with, or acting on behalf of a private review agent, may not approve or fail to approve treatment based on whether the treatment is delivered by a provider who is a participating or nonparticipating provider in the preferred provider organization or an employee assistance program network.

C. Prohibited Referrals. A private review agent or individual who is affiliated with, under contract with, or acting on behalf of a private review agent may not:

(1) Refer a patient who has undergone utilization review by that private review agent to:

(a) A health care facility in which the private review agent owns a significant beneficial interest; or

(b) A health care practice owned by the private review agent;

(2) Pay, agree to pay, accept, or agree to accept a sum for bringing or referring a patient to a private review agent; or

(3) Provide for different insurance coverage or benefits based on the patient receiving service from a health care facility or provider in which a private review agent owns a significant beneficial interest.

D. Authorized Referrals.

(1) A private review agent, or individual who is affiliated with, under contract with, or acting on behalf of a private review agent, may refer a patient to another health care provider if:

(a) The patient or health care provider requests the private review agent to provide the patient with the name of a health care provider appropriate to meet the health care needs of the patient; or

(b) The patient has no attending physician.

(2) If §D(1) of this regulation is satisfied the private review agent shall provide the patient with names of at least two health care providers appropriate to meet the health care needs of the patient.