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1. What is utilization review?

Utilization review is defined as a system for reviewing the necessary, appropriate, and efficient allocation of health care resources and services given or proposed to be given to a patient or group of patients. §38.70.10(1)

2. What is a private review agent?

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

Section §38.70.10(2)

3. Who is subject to the state’s utilization review laws?

View the Subjects of the State's Utilization Review Laws page for information.

4. Is it required for a private review agent performing utilization review on single-employer, self-insured health plans to obtain a license?

No. Private review agents performing utilization reviews only for single-employer, self-insured employee health plans are not required to obtain a certificate. South Carolina Regulation 69-47 (H)(2)

5. Is the license transferable?

No. A utilization review license is not transferable. If the business is sold or transferred, the issued certificate will automatically cancel. The surviving business must apply for a new certificate. SC Regulations §38.70.10(5)

6. Where can I find the laws and regulations that govern utilization review and private review agents?

The laws and regulations that govern utilization review and private review agents are found in §38.70 and SC Regulation 69-47.

7. What are the licensing requirements to become licensed as a utilization review and private review agent?

The licensing requirements are:

• 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

8. How often must licensure be renewed?

Every two years, beginning on July 1 of even-numbered years. SC Regulation §38.70.50

9. What are the licensure fees (initial and renewal)?

The application fee is $400 and the biennial/renewal fee is $800. SC Regulation 69-47 (3)(A)

10. When does a utilization review and private review certificate of license expire?

All certificate of license expire on June 30 of each even-numbered year. SC Regulation §38.70.50(A)

11. Does South Carolina recognize Utilization Review Accreditation Commission (URAC) accreditation?

No. South Carolina does not recognize URAC accreditation.

12. Are there any other requirements of utilization review and private review agents?

Yes. View the Private Review Agent Application Requirements page for more information.

13. Where do you file complaints?

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