Sec. 15. (a) The following requirements apply to an enrollee's request for certification by a utilization review agent of an admission, a service, or a procedure:
(1) In the absence of contractual terms to the contrary, the enrollee is responsible for notifying the utilization review agent of the admission, service, or procedure in a timely manner and for obtaining certification of health care services.
(2) A utilization review agent shall allow the provider of record or a responsible patient representative, including a family member, to assist the enrollee in fulfilling the enrollee's responsibility under subdivision (1).
(3) The provider of record shall, within a reasonable time, provide to the utilization review agent all relevant information necessary to certify the admission, service, or procedure. For an emergency admission or procedure, the information shall be provided within two (2) business days after the emergency admission or procedure. For an elective admission, procedure, or treatment, the information shall be provided not later than two (2) business days before the admission or the provision of the procedure or treatment.
(b) The failure to provide the information required by this section may result in the denial of certification in accordance with the terms of the enrollee's insurance policy, health maintenance organization contract, or other benefit program.
As added by P.L.128-1992, SEC.1.