645—43.3 (514F) Utilization and cost control review.
	 43.3(1) The board shall establish utilization and cost control review (UCCR) committee(s). A UCCR committee shall be established by approval of the board upon a showing that the committee meets the requirements of this rule. The name of each committee and a list of committee members shall be on file with the board and available to the public. As a condition of board approval, each committee shall agree to submit to the board an annual report which meets the requirements of this rule.
	 43.3(2) Each member of a UCCR committee shall:
	  a.   	 Hold a current license in Iowa.
	  b.   	 Have practiced chiropractic in the state of Iowa for a minimum of five years prior to appointment.
	  c.   	 Be actively involved in a chiropractic practice during the term of appointment as a UCCR committee member.
	  d.   	 Have no pending disciplinary action, no disciplinary action taken during the three years prior to appointment, and no disciplinary action pending or taken during the period of appointment.
	  e.   	 Have no malpractice judgment awarded or settlement paid during the three years prior to appointment or during the period of appointment.
	  f.   	 Not assist in the review or adjudication of claims in which the committee member may reasonably be presumed to have a conflict of interest.
	  g.   	 Rescinded IAB 5/10/06, effective 6/14/06.
	 43.3(3) Procedures for utilization and cost control review. A request for review may be made to the UCCR committee by any person governed by the various chapters of Title XIII, subtitle 1, of the Iowa Code, self-insurers for health care benefits to employees, other third-party payers, chiropractic patients or licensees.
	  a.   	 There shall be a reasonable fee, as established by the UCCR committee and approved by the board, for services rendered, which will be made payable directly to the UCCR committee that conducts the review. Each UCCR committee approved by the board shall make a yearly accounting to the board.
	  b.   	 A request for service shall be submitted to the executive director of the UCCR committee on a submission form approved by the board, and shall be accompanied by the number of copies required by the UCCR committee.
	  c.   	 The UCCR committee shall respond in writing to the parties involved with its findings and recommendations within 90 days of the date the request for review was submitted. The committee shall review the appropriateness of levels of treatment and give an opinion as to the reasonableness of charges for diagnostic or treatment services rendered as requested.
	 43.3(4) Types of cases reviewed shall include:
	  a.   	 Utilization.
	 (1) 	 Frequency of treatment;
	 (2) 	 Amount of treatment;
	 (3) 	 Necessity of service;
	 (4) 	 Appropriateness of treatment.
	  b.   	 Usual and customary service.
	 43.3(5) Criteria for review may include but are not limited to:
	  a.   	 Was diagnosis compatible and consistent with information?
	  b.   	 Were X-ray and other examination procedures adequate, or were they insufficient or unrelated to history or diagnosis?
	  c.   	 Were clinical records adequate, complete, and of sufficient frequency?
	  d.   	 Was treatment consistent with diagnosis?
	  e.   	 Was treatment program consistent with scientific knowledge and with academic and clinical training provided in accredited chiropractic colleges?
	  f.   	 Were charges reasonable and customary for the service?
	 43.3(6) Confidentiality. Members of the UCCR committee shall observe the requirements of confidentiality imposed by Iowa Code chapter 272C.
	 43.3(7) Annual report. Each UCCR committee shall annually submit a report to the board, and shall meet to review that report with the board chairperson or designee upon the board’s request. The annual report shall include the following information:
	  a.   	 The fee to be charged the party requesting UCCR review.
	  b.   	 A report regarding the activities of the committee for the past year, including a report regarding each review conducted, the conclusions reached regarding that review, and any recommendations made following the review.
	 43.3(8) A conclusion or recommendation, or both, made by a UCCR committee does not constitute a decision of the board.