NC S397

Clarifies that statistical review of a health care provider's or facility's practice patterns does not constitute utilization review, unless that review is used to adjudicate claims or approve or deny services to insured individuals.

Excludes entities performing only statistical practice pattern analysis from the definition of "utilization review organization" (URO) if such review is not used in claims adjudication or service approval decisions.

Modifies G.S. 58-50-61(a) to specify that utilization review techniques include ambulatory review, case management, certification, concurrent review, discharge planning, prospective review, retrospective review, and second opinion evaluations.

Establishes that retrospective review excludes claims review limited to reimbursement levels, documentation verification, coding accuracy, or payment adjudication, but includes review of emergency services claims under the prudent layperson standard.

Effective upon enactment.