Utilization Review Agent
What Is a Utilization Review Agent
A utilization review agent (URA), defined in ARS § 20-2501, determines the medical necessity and appropriateness of health care services.
Who Must Be Registered?
A URA must register with the Arizona Department of Insurance to perform utilization review for fully insured commercial business. Government coverage, such as Medicare or Medicaid are not insurance products regulated by the Department of Insurance under Title 20. Therefore, registration is not required to perform utilization review for Medicare and Medicaid.
Other entities exempt from Arizona Department of Insurance URA registration requirements are:
- An entity that only conducts internal utilization review for hospitals, home health agencies, clinics, private offices, or other health-provider facilities if the review does not result in a decision to approve or deny payment for hospital or medical services. ARS § 20-2502(B)(2).
- An entity that only conducts utilization review activities for work related injuries and illnesses covered under the workers’ compensation laws in ARS Title 23. ARS § 20-2502(B)(3).
- An entity that only conducts utilization review activities for a self-funded or self-insured employee benefit plan if the regulation of that plan is preempted by Section 514(b) of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 USC § 1144(b). ARS § 20-2502(B)(4).
Please contact the Life and Health Division at (602) 364-2393 for details on how to become registered in Arizona to perform utilization review for fully insured commercial business.