Utilization Review Licensing in New Hampshire

Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in New Hampshire. For assistance with licensing, please contact us to learn about our software and managed license services.

New Hampshire Independent Review Organization (IRO) Certification

Type of Review:

Health Care

Agency:New Hampshire Insurance Department
Law:

New Hampshire Admin Code Ins 2703.07

Foreign Qualification is Prerequisite:No
Registered Agent (Special Agency) Required?No
Fact Checked:2/19/21

Initial Registration

Form:

Application for Certification as an Independent Review Organization

Agency Fee:

$0

Required Attachments:
  • List of references, preferably other state insurance departments
  • Copy of applicant’s certificate of IRO accreditation (e.g., NCQA or URAC certificates)
  • Copy of applicant’s organization chart, identifying officers and key staff positions
Fact Checked:2/19/21

Registration Renewal

Agency Fee:

$0

Due:

Biennially

Fact Checked:2/19/21

Supplemental Reporting
Annual Report

Agency Fee:

$0

Due:

Annually

Notes:

Reports must include:

  • The total number of requests for external review assigned by the commissioner to the independent review organization
  • The total number of requests for external review assigned by the commissioner to the independent review organization for which a final adjudication was made, and, of those, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination
  • The average length of time required for the adjudication
  • A summary of the types of coverages or cases for which an external review was sought
  • The number of external reviews that were terminated prior to completion as the result of a reconsideration and reversal by the health carrier of its adverse determination or final adverse determination after the receipt of new or additional information from the covered person or the covered person’s authorized representative
  • The number of external reviews that were terminated prior to completion as the result of a settlement between the health carrier and the covered person on terms other than the original determination of the health carrier or a complete reversal of that determination
  • The number of external reviews that were terminated prior to completion for other reasons
  • Verification that the organization maintains written records fully documenting requests for external review received from the commissioner
Fact Checked:2/19/21

New Hampshire Medical Utilization Review License

Type of Review:

Medical Utilization Review

Agency:New Hampshire Insurance Department
Law:

RSA 420-E:2

Fact Checked:2/18/21

Initial Registration

Form:

Application for License as a Medical Utilization Review Entity

Agency Fee:

$500

Required Attachments:
  • List of states where the entity does business
  • List of principal proprietors, partners, directors, officers and administrators and others responsible for the operation, management and control of the entity
  • Biographical sketches of all persons listed in the above requirement
  • List of office locations including numbers of employees at those locations
  • A description of the types of review the entity offers
  • Copies of all materials used by the applicant to inform beneficiaries of the requirements of the utilization review plan and the rights and responsibilities of beneficiaries under the plan
  • A description of the procedures established by the applicant for preserving the confidentiality of medical information used in the utilization review process
  • A copy of the accreditation certificate received from URAC (if applicable)
Fact Checked:2/18/21

Registration Renewal

Form:

Application for License as a Medical Utilization Review Entity

Agency Fee:

$100

Due:

Annually by March 31.

Fact Checked:2/18/21

New Hampshire Resources

Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

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