§36-6475.7. External review procedure.
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A. 1. Except as provided in subsection B of this section, a request for an external review pursuant to Section 6475.8, 6475.9, or 6475.10 of this title shall not be made until the covered person has exhausted the health carrier's internal grievance process.
2. A covered person shall be considered to have exhausted the health carrier's internal grievance process for purposes of this
section, if the covered person or the covered person's authorized representative:
a. has filed a grievance involving an adverse
determination, and
b. except to the extent the covered person or the covered
person's authorized representative requested or agreed
to a delay, has not received a written decision on the
grievance from the health carrier within thirty
days following the date the covered person or the
covered person's authorized representative filed the
grievance with the health carrier.
3. Notwithstanding paragraph 2 of this subsection, a covered person or the covered person's authorized representative may not make a request for an external review of an adverse determination involving a retrospective review determination made pursuant to Sections 6551 through 6565 of this title until the covered person has exhausted the health carrier's internal grievance process.
B. 1. a. At the same time a covered person or the covered
person's authorized representative files a request for
an expedited review of a grievance involving an
adverse determination, the covered person or the
covered person's authorized representative may file a
request for an expedited external review of the
adverse determination:
(1)under Section 6475.9 of this title if the covered
person has a medical condition where the time
frame for completion of an expedited review of
the grievance involving an adverse determination
would seriously jeopardize the life or health of
the covered person or would jeopardize the
covered person's ability to regain maximum
function, or
(2)under Section 6475.10 of this title if the
adverse determination involves a denial of
coverage based on a determination that the
recommended or requested health care service or
treatment is experimental or investigational and
the covered person's treating physician certifies
in writing that the recommended or requested
health care service or treatment that is the
subject of the adverse determination would be
significantly less effective if not promptly
initiated.
b. Upon receipt of a request for an expedited external
review under subparagraph a of this paragraph, the
independent review organization conducting the
external review in accordance with the provisions of
Section 6475.9 or 6475.10 of this title shall
determine whether the covered person shall be required
to complete the expedited review process before it
conducts the expedited external review.
c. Upon a determination made pursuant to subparagraph b
of this paragraph that the covered person must first
complete the expedited grievance review process, the
independent review organization immediately shall
notify the covered person and, if applicable, the
covered person's authorized representative of this
determination and that it will not proceed with the
expedited external review set forth in Section 6475.9
of this title until completion of the expedited
grievance review process and the covered person's
grievance at the completion of the expedited grievance
review process remains unresolved.
2. A request for an external review of an adverse determination may be made before the covered person has exhausted the health carrier's internal grievance procedures whenever the health carrier agrees to waive the exhaustion requirement.
C. If the requirement to exhaust the health carrier's internal grievance procedures is waived under paragraph 2 of subsection B of this section, the covered person or the covered person's authorized representative may file a request in writing for a standard external review as set forth in Section 6475.8 or 6475.10 of this title. Added by Laws 2011, c. 278, § 41. Amended by Laws 2011, c. 360, § 31; Laws 2022, c. 154, § 14, eff. Nov. 1, 2022.