2005 Vermont Code - § 4099a. — Utilization review; required

§ 4099a. Utilization review; required

(a) The insurer shall review inpatient, outpatient, and partial institutional rehabilitation services and, within 15 days of the review, shall deny payment for any service which it deems to be inappropriate.

(b) In the event of a denial under subsection (a) of this section, the insured or the provider of the service for which payment is denied may appeal the denial to the commissioner of banking, insurance, securities, and health care administration. In the event the commissioner affirms the denial, payment shall not be made by the insurer, nor shall the patient be held liable for payment for services determined to be inappropriate.

(c) An insurer, insured or provider aggrieved by the commissioner's determination may appeal such determination pursuant to Rule 75 of the Vermont Rules of Civil Procedure to the superior court of the county in which the insurer or provider resides. (Added 1985, No. 75, § 5, eff. March 1, 1986; amended 1989, No. 225 (Adj. Sess.), § 25(b); 1995, No. 180 (Adj. Sess.), § 38(a).)