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 fill out this Additional Questionnaire 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 Law 38-51:
   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

Renewal

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

1. 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.
2. Renewal fee is $800. 
3. The renewal application and renewal fee must be completed on NIPR. There is additional information that will need to be submitted to the SC Department of Insurance to complete your renewal. Please fill out this Additional Questionnaire and email to the Specialty Licensing Team.