Vermont § 4064 - Mental health services review

§ 4064. Mental health services review

• (a) The purposes of this section are to: (1) promote the delivery of quality mental health services in a cost-effective manner; (2) foster the practice of mental health services review as a professional collaborative
  process, the primary objective of which is to enhance the effectiveness of clinical
  treatment; (3) protect clients and patients, employers, and mental health providers by ensuring that
  review agents are qualified to perform service review activities and to make informed
  decisions on the appropriateness of mental health care; and (4) ensure the confidentiality of clients’ and patients’ mental health records in the
  performance of service review activities in accordance with applicable State and federal
  laws. (b) Definitions. As used in this section: (1) “License” means a review agent’s license granted by the Commissioner. (2) “Mental health provider” means any individual, corporation, facility, or institution
  certified or licensed by this State to provide mental health services, including a
  physician, nurse with recognized psychiatric specialties, hospital or other health
  care facility, psychologist, clinical social worker, mental health counselor, alcohol
  or drug abuse counselor, or an employee or agent of such mental health provider acting
  in the course and scope of employment or an agency related to mental health services. (3) “Mental health services” mean acts of diagnosis, treatment, evaluation, or advice
  or any other acts permissible under the health care laws of Vermont, whether performed
  in an outpatient or institutional setting, and include treatment for substance use
  disorder. (4) “Review agent” means a person or entity performing service review activities within
  one year following the date of submission of a fully compliant application for licensure
  who is affiliated with, under contract with, or acting on behalf of a business entity
  in this State and who provides or administers mental health benefits to members of
  health insurance plans subject to the Department’s jurisdiction, including a health
  insurer. (5) “Service review” means any system for reviewing the appropriate and efficient allocation
  of mental health services given or proposed to be given to a client or patient, or
  to a group of clients or patients, for the purpose of recommending or determining
  whether the services should be covered and includes activities of utilization review
  and managed care, but does not include professional peer review that does not affect
  reimbursement for or provision of services. (c) Any person who approves or denies payment, or who recommends approval or denial of
  payment, for mental health services, or whose review results in approval or denial
  of payment for mental health services on a case-by-case basis, shall not review these
  services in this State unless the Commissioner has granted the person a review agent’s
  license. The Commissioner shall adopt rules to implement the provisions of this section,
  including the procedures and standards for licensure. The rules shall differentiate
  between health maintenance organizations licensed to do business within this State
  and other forms of utilization review. The rules shall establish: (1) A requirement that within 10 business days after receiving a request for them, the
  review agent shall make available at no cost to the clients, patients, and providers
  affected by its service review activities the specific review criteria and standards,
  credentials of the reviewing professionals, and procedures and methods to be used
  in evaluating proposed or delivered mental health services. (2) A time period within which any determination regarding the provision or reimbursement
  of mental health services shall be made. (3) A requirement that any determination regarding mental health services rendered or
  to be rendered to a client or patient that may result in a denial of third-party reimbursement
  or a denial of precertification for that service shall include the evaluation, findings,
  and concurrence of a mental health professional whose training and expertise is at
  least comparable to that of the treating mental health provider. (4) The type, qualifications, and number of personnel required to perform service review
  activities. (5) A requirement that a determination by a review agent that care rendered or to be rendered
  is inappropriate shall not be made until the review agent has communicated with the
  patient’s attending mental health provider concerning that care. The review shall
  be prospective or concurrent with the treatment. (6) A requirement that any determination that care rendered or to be rendered is inappropriate
  shall include the written evaluation and findings of the review agent. (7) A procedure for clients, patients, mental health providers, and hospitals to seek
  prompt reconsideration before an independent review organization pursuant to section 4063 of this title of an adverse decision by a review agent. The external reviewer engaged by the independent
  review organization shall have training and expertise at least comparable to that
  of the treating health care provider. (8) Policies and procedures to ensure that all applicable State and federal laws to protect
  the confidentiality of individual mental health records are followed. (9) Policies and procedures that ensure appropriate notification and concurrence of providers
  and their clients or patients before client or patient interviews are conducted by
  the review agent. (10)(A) Prohibition of an agreement between the review agent and a business entity or third-party
  payor in which payment to the review agent includes an incentive or contingent fee
  arrangement based on the reduction of mental health services, reduction of length
  of stay, reduction of treatment, or treatment setting selected. (B) Nothing in this subdivision (10) shall prohibit capitation arrangements for reimbursement
  for mental health services. (C) A clinical decision made by the attending mental health provider regarding continued
  treatment shall not be construed as a denial of services subject to the provisions
  of this section. (d) Reviewing agents shall be subject to the provisions of chapter 129 of this title governing
  unfair insurance trade practices. (e) The Commissioner shall have the authority to examine, take administrative action against,
  and penalize review agents as provided in chapters 3, 101, and 129 of this title.
  A person who violates any provision of this section or who submits any false information
  in an application required by this section may be fined not more than $5,000.00 for
  each violation. (f) A review agent shall pay a license fee of $200.00 for the year of registration and
  a renewal fee of $200.00 for each year thereafter. In addition, a review agent shall
  pay any additional expenses incurred by the Commissioner to examine and investigate
  an application or an amendment to an application. (g) The confidentiality of any health care information acquired by or provided to an independent
  review organization pursuant to section 4063 of this title shall be maintained in compliance with any applicable State or federal laws. Records
  of, and internal materials prepared for, specific reviews under this section shall
  be exempt from public inspection and copying under the Public Records Act. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)