Frequently Asked Questions

Utilization review is defined as a system for reviewing the necessary, appropriate, and efficient allocation of healthcare resources and services given or proposed to be given to a patient or group of patients. SC Code of Laws §38-70-10(1)

A private review agent is defined as a person performing utilization reviews who is either under contract with or acting on behalf of, but not employed by:

• A hospital
• A South Carolina business entity
• The State of South Carolina

SC Code of Laws §38-70-10(2)

No. Private review agents performing utilization reviews only for single-employer, self-insured employee health plans are not required to obtain a certificate. SC Code of Regulation 69-47 (H)(3)

No. A utilization review license is not transferable. If the business is sold or transferred, the issued certificate will automatically be canceled. The surviving business must apply for a new certificate. SC Code of Laws §38-70-10(5)

The laws and regulations that govern utilization review and private review agents are found in SC Code of Laws §38-70 and SC Code of Regulation 69-47.

• Complete a application packet
• Submit a licensing fee of $1,200 dollars
• File a copy of certificate of authority from home state, letter of good standing, and copy of articles of incorporation
• Provide list(s) of toll free number for accessibility
• Provide number of incoming telephone lines
• Provide incoming call queue time
• Submit all materials designed to inform applicable patients of the requirements of the utilization plan

Every two years, beginning on July 1 of even-numbered years. SC Code of Laws §38-70-50

The application fee is $400 and the biennial/renewal fee is $800. SC Regulation 69-47 (III)(A)

All certificates of license expire on June 30 of each even-numbered year. SC Code of Laws §38-70-50(A)

Complaints are filed with the South Carolina Department of Insurance. Complaints should be addressed to the Consumer Service Division.