Utilization Review Licensing in South Carolina

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 South Carolina. For assistance with licensing, please contact us to learn about our software and managed license services.

South Carolina Utilization Review Agent Registration

Type of Review:

Medical Utilization Review

Agency:South Carolina Department of Insurance
Law:

SC Code § 38-70-20

Notes:

Insurance companies, administrators of insurance benefit plans, and health maintenance organizations (HMOs) licensed and regulated by the South Carolina Department of Insurance are exempt from the certification requirements for private review agents. Private review agents performing utilization reviews only for single-employer, self-insured employee health plans are also exempt from the certification requirements.

Fact Checked:2/18/21

Initial Registration

Form:

File an Additional Questionnaire form with the department and file an online application through NIPR.

Filing Method:

Online through NIPR

Agency Fee:

$1,200

Fact Checked:2/18/21

Registration Renewal

Form:

File an Additional Questionnaire form with the department and file an online application through NIPR.

Filing Method:

Online through NIPR

Agency Fee:

$800

Due:

Biennially by the date of issuance.

Fact Checked:2/18/21

South Carolina 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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