[ §432E-33] Request for external review.

273 words·~1 min read·/hi/432e-33

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

(a)All requests for external review of a health carrier's adverse action shall be made in writing to the commissioner and shall include:

(1)A copy of the final internal determination of the health carrier, unless exempted pursuant to subsection (b);

(2)A signed authorization by or on behalf of the enrollee for release of the enrollee's medical records relevant to the external review;

(3)A disclosure for conflict of interests evaluation, as provided in section 432E-43; and

(4)A filing fee of $15, which shall be deposited into the compliance resolution fund established pursuant to section 26-9(o); provided that the filing fee shall be refunded if the adverse determination or final internal adverse determination is reversed through external review.

The commissioner shall waive the filing fee required by this subsection if the commissioner determines that payment of the fee would impose an undue financial hardship to the enrollee. The annual aggregate limit on filing fees for any enrollee within a single plan year shall not exceed $60.

(b)The internal appeals process of a health carrier shall be completed before an external review request shall be submitted to the commissioner except in the following circumstances:

(1)The health carrier has waived the requirement of exhaustion of the internal appeals process;

(2)The enrollee has applied for an expedited external review at the same time that the enrollee applied for an expedited internal appeal; provided that the enrollee is eligible for an expedited external review; or

(3)The health carrier has substantially failed to comply with its internal appeals process. [L 2011, c 230, pt of §2]