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Arkansas Code Title 23. Public Utilities and Regulated Industries § 23-79-2103. Clinical review criteria

Current as of March 28, 2024 | Updated by Findlaw Staff

(a)(1) Clinical review criteria used to establish a step therapy protocol shall be based on clinical practice guidelines that:

(A) Are developed and endorsed by a multidisciplinary panel of experts that manages conflicts of interest among the members of the writing and review groups by:

(i)(a) Requiring members to disclose any potential conflicts of interest with entities, including healthcare insurers, health benefit plans, and pharmaceutical manufacturers.

(b) A member shall recuse himself or herself from voting if the member has a conflict of interest;

(ii) Using a methodologist to work with writing groups to provide objectivity in data analysis and ranking of evidence through the preparation of evidence tables and facilitating consensus; and

(iii) Offering opportunities for public review and comments;

(B) Are based on high-quality studies, research, and medical practice;

(C) Are created by an explicit and transparent process that:

(i) Minimizes biases and conflicts of interest;

(ii) Explains the relationship between treatment options and outcomes;

(iii) Rates the quality of the evidence supporting recommendations; and

(iv) Considers relevant patient subgroups and preferences; and

(D) Are continually updated through a review of new evidence, research, and newly developed treatments.

(2) Peer-reviewed published medical literature may be substituted for clinical practice guidelines to establish clinical review criteria if the peer-reviewed published medical literature meets the requirements of subdivisions (a)(1)(B) and (C) of this section, when those requirements apply to the available peer-reviewed published medical literature.

(3) If establishing a step therapy protocol, a utilization review agent shall take into account the needs of atypical patient populations and diagnoses when establishing clinical review criteria.

(4) A healthcare insurer, pharmacy benefit manager, or utilization review organization shall:

(A) Upon written request, provide all specific written clinical review criteria relating to the particular condition or disease, including clinical review criteria relating to a step therapy protocol override determination; and

(B) Make available such clinical review criteria and other clinical information on its website and to a healthcare professional on behalf of an insured upon written request.

(b) This section does not require healthcare insurers, health benefit plans, or the state to set up a new entity to develop clinical review criteria used for step therapy protocols.

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Cite this article: FindLaw.com - Arkansas Code Title 23. Public Utilities and Regulated Industries § 23-79-2103. Clinical review criteria - last updated March 28, 2024 | https://codes.findlaw.com/ar/title-23-public-utilities-and-regulated-industries/ar-code-sect-23-79-2103/

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