§431M-3 - Peer review. - Hawaii Statutes

     §431M-3  Peer review.  (a)  Covered benefits for alcohol dependence, drug dependence, or mental illness insurance policies, hospital or medical service plan contracts, and health maintenance organization health plan contracts shall be limited to those services certified by the insurance or health care plan carrier's physician, psychologist, licensed clinical social worker, marriage and family therapist, licensed mental health counselor, or advanced practice registered nurse as medically or psychologically necessary at the least restrictive appropriate level of care.

     (b)  All alcohol dependence, drug dependence, or mental illness treatment or services as set forth in this chapter shall be subject to peer review procedures as a condition of payment or reimbursement, to assure that reimbursement is limited to appropriate utilization under criteria incorporated into insurance policies or health or service plan contracts either directly or by reference.  Review may involve prior approval, concurrent review of the continuation of treatment, post-treatment review or any combination of these.  However, if prior approval is required, provision shall be made to allow for payment of urgent or emergency admissions, subject to subsequent review. [L 1988, c 202, pt of §1, §3; am L 1994, c 111, §4; am L 1997, c 247, §2 and c 273, §2; am L 1998, c 78, §3; am L 2002, c 167, §4 and c 239, §1; am L 2007, c 38, §2; am L 2008, c 206, §3]