Title 38, Chapter 70 of the South Carolina Code of Laws defines the regulations and requirements for utilization reviews and private review agents. A utilization review is a system for reviewing health care resources and services for a patient or group of patients, and a private review agent is the person who performs the review.
Insurance companies, administrators of insurance benefit plans, and health maintenance organizations (HMOs) licensed and regulated by the South Carolina Department of Insurance are exempt from the certification requirements for private review agents. Private review agents performing utilization reviews only for single-employer, self-insured employee health plans are also exempt from the certification requirements. However, all companies, administrators, HMOs, and agents, whether licensed by the department or exempt from certification, must comply with the standards and procedures for utilization reviews as mandated by South Carolina law.
Utilization review licenses are non-transferable. If a business is sold or transferred, the issued certificate will automatically cancel and the surviving business must apply for a new certificate.
South Carolina does not recognize Utilization Review Accreditation Committee (URAC) accreditation.