Utilization Review Company (URC)
Definition
UTILIZATION REVIEW (UR) – means the use of a set of formal techniques designed to monitor the use of, or evaluate the medical necessity, appropriateness, efficacy, or efficiency of, health care services, health care procedures or health care settings. Such techniques may include the monitoring of or evaluation of (A) health care services performed or provided in an outpatient setting, (B) the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility, (C) opportunities or requirements to obtain a clinical evaluation by a health care professional other than the one originally making a recommendation for a proposed health care service, (D) coordinated sets of activities conducted for individual patient management of serious, complicated, protracted or other health conditions, or (E) prospective review, concurrent review, retrospective review or certification.
Applicable Statutes
C.G.S. §38a-591a through §38a-591n & Insurance Department Regulations §38a-591-1 through §38a-591-11 – see Laws and Regulations
Fees
Initial: $6,000.00
Reinstatement: $6,000.00
Renewal: $6,000.00
Note: Change in fee based on CT Public Act 22-84 effective 1/1/23.
No pro-rating, non-refundable application fee. Plus a nominal NIPR application fee
Duration
Two (2) years – Renewal Applications are due each October 1st for a renewal effective January 1st. The NIPR System is not available to input your renewal until early September.
All applications will renew bi-annually starting effective 01/01/2023 and each odd numbered year thereafter. If you have a new application within the two-year period you will still renew on the 1st of each odd numbered year.
How to Apply
- Apply by going to National Insurance Producer Registry (NIPR). Under Licensing Center, select “Apply for a New License.”
- The 2nd Utilization Review – Company License Application (CT Specific UR Application) must be completed and attached to the NIPR warehouse. All required policies/procedures and required letters must be in redlined format from the previously approved forms and must also be added to the NIPR warehouse.
- Please note that the External Review Application and the External Review Program Flyer were revised in 2021. Both the application and flyer must be enclosed as attachments to all appeal denials in CT pursuant to Insurance Department Regulation §38a-591-8 (b), which requires the appeal adverse determination to include language “all internal appeals have been exhausted” as well as including procedure to apply for an external appeal, as well as the requirement to include a copy of the External Review Application (effective 10/1/21) and the External Review Program Flyer. (You only need to attach 1 copy of the form in NIPR warehouse and simply show the forms as enclosures at the end of all appeal denials.)
- Residents – Step by Step Instructions
- Non-Residents – Step by Step Instructions
How to Renew
- Renewal notices are EMAILED about 120 days before the expiration date.
- Apply by going to National Insurance Producer Registry (NIPR). Under Licensing Center, select “Renew an Existing License.”
- The renewal process is the same as the application process – Licensing & Renewal Requirements for Utilization Review Companies must be redlined from the previously approved policies and letters, completed and attached to the NIPR warehouse.
- Residents – Step by Step Instructions
- Non-Residents – Step by Step Instructions
How to Amend Lines of Authority
Not applicable.
How to Reinstate a License
- Apply by going to National Insurance Producer Registry (NIPR). Under Licensing Center, select “Apply for a New License.”
- The 2nd Utilization Review – Company License Application must be completed and attached to the NIPR warehouse. All required policies/procedures and required letters must be in redlined format from the previously approved forms and must also be added to the NIPR warehouse.
- Please note that the External Review Application and the External Review Program Flyer were revised in 2021. Both the application and flyer must be enclosed as attachments to all appeal denials in CT pursuant to Insurance Department Regulation §38a-591-8 (b), which requires the appeal adverse determination to include language “all internal appeals have been exhausted” as well as including procedure to apply for an external appeal, as well as the requirement to include a copy of the External Review Application (effective 10/1/21) and the External Review Program Flyer. (You only need to attach 1 copy of the form in NIPR warehouse and simply show the forms as enclosures at the end of all appeal denials.)
- Residents – Step by Step Instructions
- Non-Residents – Step by Step Instructions
How to change License information (i.e.: demographics)
Update your License Information (use to update contact name, email, telephone, addresses, unless residency or state of residency changes)
Material changes to policies, letters and criteria which must be reviewed:
Submit the revised redlined policies, letters, clinical cretiria, or other changes by attaching in the NIPR warehouse under ROA (reporting of actions) for review. Submit an email to LHCompliance@ct.gov to advise that a material change has been added in ROA section in the NIPR warehouse.
Print a copy of the license
Initial Education Requirements
Not applicable.
Waivers due to Designations
Not applicable.
Renewal Continuing Education (CE) Requirements
Not applicable.
Cancel License
Attach the request with the company name, NPN, FEIN and the date to terminate into the NIPR warehouse under ROA section. Then submit an email to LHCompliance@ct.gov to advise them that it has been added for processing.