Private Review Agent Application Requirements

Title 38, Chapter 51 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.

South Carolina does not recognize Utilization Review Accreditation Committee (URAC) accreditation.

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 form 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:

a. Written Utilization Review program 
i. Information upon which the utilization review and retrospective review 
   is conducted
b. Material deigned to inform applicable patients of:
i. Adverse Decision
ii. Appeal and appeal process
iii. Rights and confidentiality
iv. Qualification of Personnel