Utilization Review/ Private Review Agent

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.

As stated in SC Code of Regulations 69-47, 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.

Initial Application

1. The initial application and fee of $1,200 must be completed on NIPR. 
2. There is additional information that will need to be submitted to the SC Department of Insurance to complete your application. Please complete this Additional Questionnaire and Application Checklist and email to the Specialty Licensing team.
3. Please send a copy of the Utilization Review Program to the Specialty Licensing team. The program must have the following, in accordance with SC Code of Laws §38-70.
   1. Written Utilization Review program  
   2. Information upon which the utilization review and retrospective review is conducted
   3. Material designed to inform applicable patients of:
      1. Adverse Decision
      2. Appeal and appeal process
      3. Rights and confidentiality
      4. Qualification of Personnel

Please be aware that all correspondence regarding this application will be conducted via email through our online system. The email address used for this correspondence is sbs@naic.org. We recommend saving this email address to ensure you receive any future system-generated emails. However, please do not reply to sbs@naic.org, as messages sent to that address will not be received. For any correspondence and documents you wish to submit regarding your license, please send them to specialtylicensing@doi.sc.gov.

Renewal

Here is a navigation tool to use for renewals through NIPR.

The renewal is due between April 1 to June 30 on every even year. You will not be able to process the renewal through NIPR until the renewal is open on even years. The renewal fee is $800. It's best to apply early to have enough time to resolve any issues that may arise to avoid a lapsed license and/or penalty fees.

We are in the process of updating the application checklist and forms required for renewal. Once the updates are complete, the new forms will be available on this webpage. We will also send an email notification to all licensed Utilization Review/Private Review Agents on or before April 1, 2026, informing them of the renewal requirements and directing them to the updated forms on this page.

Please be aware that all correspondence regarding this application will be conducted via email through our online system. The email address used for this correspondence is sbs@naic.org. We recommend saving this email address to ensure you receive any future system-generated emails. However, please do not reply to sbs@naic.org, as messages sent to that address will not be received. For any correspondence and documents you wish to submit regarding your license, please send them to specialtylicensing@doi.sc.gov.