Title 38, Chapter 70 of the South Carolina Code of Laws defines the regulations and requirements for utilization reviews and private review agents. A utilization review is a system for reviewing health care resources and services for a patient or group of patients, and a private review agent is the person who performs the review.
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. However, all companies, administrators, HMOs, and agents, whether licensed by the Department or exempt from certification, must comply with the standards and procedures for utilization reviews as mandated by South Carolina law.
Utilization review licenses are non-transferable. If a business is sold or transferred, the issued certificate will automatically cancel and the surviving business must apply for a new certificate.
South Carolina does not recognize Utilization Review Accreditation Committee (URAC) accreditation.
Utilization Review and Private Review Agent Frequently Asked Questions
- Notification of an adverse decision by the private review agent must be provided to the insured or other party designated by the insured within five business days either by telephone or fax.
- Private review agents must have written procedures to assure that utilization reviews are conducted in a timely manner and for appeals of denials of certification.
- Private review agents must make a certification determination within two working days of receipt of the necessary information and must make a certification determination of an extended stay or additional service within one working day of receipt of the additional information. Private review agents must not routinely conduct daily review on all such stays.
Private Review Agent licenses are renewed on July 1st of even-numbered years. The following information must be submitted to the Department by June 30th of even-numbered years. Renewals received after June 30th are subject to administrative disciplinary action. Failure to complete your renewal will prevent your organization from performing utilization reviews in this state.
All signatures and documents must be original. Documents with reproduced or stamped signatures will not be accepted. Faxed documents will also not be accepted. All questions must be thoroughly answered. Improperly completed or incomplete renewals will not be accepted and will be returned.
License Renewal Application, Form 1031rn
Application Help Information
Section 1. List major owner(s) and percentage or ownership if organization type
is corporation or partnership.
Section 2. Attach Certificate of Authority, Letter of Good Standing or Articles of
Section 3. List other organization locations.
Section 4. List all partners or officers.
Section 5. Provide hours of operation and toll free number
Copy of your "Utilization Review Program."
- Provide an accessibility plan of operation for weekends and holidays.
- Provide both a list indicating the total of all reviewing personnel, by specific qualification or specialty. Additionally, include a total of all physicians, by specialty, which support and/or supervise reviewing personnel.
- Provide the total number of covered lives for which the reviewing personnel of your company may be required to perform utilization review activities.
- Provide a copy of all materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under each contract.
- Provide the applicants procedures for notification of an adverse decision. Include all forms used in adverse decision notification process.
- Provide the applicants appeal procedures by which insured and providers may seek reconsideration of determinations by the applicant’s utilization review personnel. Include all appropriate forms used within the appeals process.
- Provide the applicants internal procedures currently in place to protect the confidentiality of individual medical records.
- Specifically list all state and federal laws, which were reviewed by the applicant to develop these procedures.
3. $800 Renewal Fee
SCDOI Contact Information