A utilization review agent (URA), defined in ARS § 20-2501, determines the medical necessity and appropriateness of health care services.
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.
ARS § 41-1030(G) requires most Arizona government agencies to prominently print the provisions of ARS § 41-1030(B), (D), (E) and (F) on all license applications. The following is the language in ARS § 41-1030(B), (D), (E) and (F):
B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.
D. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.
E. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the agency’s adopted personnel policy.
F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
Health care insurers, pharmacy benefit managers and utilization review agents may send the annual step therapy compliance certification required by ARS 20-3653(D) to [email protected].
The certification is required annually by or before December 31st. The certification must convey whether the clinical review criteria used in the entity’s step therapy protocol for prescription drugs meets the requirements prescribed in ARS §§ 20-3651 through 20-3564. Inquiries regarding step therapy certification submissions may be sent to [email protected].
Note that the step therapy protocol requirements apply to all “health care plans that are subject to state law regulating insurance, that provides prescription drug benefits and that includes coverage for a step therapy protocol regardless of how that coverage is described.” ARS 20-3652.