The law applies to those who perform utilization reviews on behalf of, but are not employed by:
- A hospital
- A South Carolina business entity
- The State of South Carolina
Exemptions Provided
Insurance companies, administrators of insurance benefit plans, and health maintenance organizations licensed and regulated by the South Carolina Department of Insurance are exempt from the certification requirements for private review agents. §38.70.10
Health maintenance organizations (HMOs) licensed and regulated by the Department of Insurance that perform utilization review are not required to obtain a certificate. However, these HMOs must comply with such provisions as procedures for utilization review determinations, appeals process, information upon which utilization review is conducted. South Carolina Regulations 69-47
- Insurers: No
- Retrospective review: Yes
- Utilization review organizations: Yes
- Workers compensations: No