§36-6475.9. Circumstances when external review request can be made.
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A. Except as provided in subsection F of this section, a covered person or the covered person's authorized representative may make a request for an expedited external review with the Insurance Commissioner at the time the covered person receives:
1. An adverse determination if:
a. the adverse determination involves a medical condition
of the covered person for which the time frame for
completion of an expedited internal review of a
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, and
b.
the covered person or the covered person's authorized
representative has filed a request for an expedited
review of a grievance involving an adverse
determination; or
2. A final adverse determination:
a. if the covered person has a medical condition where
the time frame for completion of a standard external
review pursuant to Section 6475.8 of this title would
seriously jeopardize the life or health of the covered
person or would jeopardize the covered person's
ability to regain maximum function, or
b. if the final adverse determination concerns an
admission, availability of care, continued stay or
health care service for which the covered person
received emergency services, but has not been
discharged from a facility.
B. 1. Upon receipt of a request for an expedited external review, the Commissioner immediately shall send a copy of the request to the health carrier.
2. Immediately upon receipt of the request pursuant to paragraph 1 of this subsection, the health carrier shall determine whether the request meets the reviewability requirements set forth in subsection B of Section 6475.8 of this title. The health carrier shall immediately notify the Commissioner and the covered person and, if applicable, the covered person's authorized representative of its eligibility determination.
3. a. The Commissioner may specify the form for the health
carrier's notice of initial determination under this
subsection and any supporting information to be
included in the notice.
b. The notice of initial determination shall include a
statement informing the covered person and, if
applicable, the covered person's authorized
representative that a health carrier's initial
determination that an external review request is
ineligible for review may be appealed to the
Commissioner.
4. a. The Commissioner may determine that a request is
eligible for external review under subsection B of
Section 6475.8 of this title notwithstanding a health
carrier's initial determination that the request is
ineligible and require that it be referred for
external review.
b. In making a determination under subparagraph a of this
paragraph, the Commissioner's decision shall be made
in accordance with the terms of the covered person's
health benefit plan and shall be subject to all
applicable provisions of the Uniform Health Carrier
External Review Act.
5. Upon receipt of the notice that the request meets the reviewability requirements, the Commissioner immediately shall assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations compiled and maintained by the Commissioner pursuant to Section 6475.12 of this title. The Commissioner shall immediately notify the health carrier of the name of the assigned independent review organization.
6. In reaching a decision in accordance with subsection E of this section, the assigned independent review organization shall not be bound by any decisions or conclusions reached during the health carrier's utilization review process as set forth in Sections 6551 through 6565 of this title or the health carrier's internal grievance process.
C. Upon receipt of the notice from the Commissioner of the name of the independent review organization assigned to conduct the expedited external review pursuant to paragraph 5 of subsection B of this section, the health carrier or its designee utilization review organization shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization electronically or by telephone or facsimile or any other available expeditious method.
D. In addition to the documents and information provided or transmitted pursuant to subsection C of this section, the assigned independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision:
1. The covered person's pertinent medical records;
2. The attending health care professional's recommendation;
3. Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, the covered person's authorized representative or the covered person's treating provider;
4. The terms of coverage under the covered person's health benefit plan with the health carrier to ensure that the independent review organization's decision is not contrary to the terms of coverage under the covered person's health benefit plan with the health carrier;
5. The most appropriate practice guidelines, which shall include evidence-based standards, and may include any other practice guidelines developed by the federal government, national or professional medical societies, boards and associations;
6. Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review organization in making adverse determinations; and
7. The opinion of the independent review organization's clinical reviewer or reviewers after considering paragraphs 1 through 6 of this subsection to the extent the information and documents are available and the clinical reviewer or reviewers consider appropriate.
E. 1. As expeditiously as the covered person's medical condition or circumstances require, but in no event more than seventy-two
(72)hours after the date of receipt of the request for an expedited external review that meets the reviewability requirements set forth in subsection B of Section 6475.8 of this title, the assigned independent review organization shall:
a. make a decision to uphold or reverse the adverse
determination or final adverse determination, and
b. notify the covered person, if applicable, the covered
person's authorized representative, the health
carrier, and the Commissioner of the decision.
2. If the notice provided pursuant to paragraph 1 of this subsection was not in writing, within forty-eight
(48)hours after the date of providing that notice, the assigned independent review organization shall:
a. provide written confirmation of the decision to the
covered person, if applicable, the covered person's
authorized representative, the health carrier, and the
Commissioner, and
b. include the information set forth in paragraph 2 of
subsection I of Section 6475.8 of this title.
3. Upon receipt of the notice of a decision pursuant to paragraph 1 of this subsection reversing the adverse determination or final adverse determination, the health carrier immediately shall approve the coverage that was the subject of the adverse determination or final adverse determination.
F. An expedited external review may not be provided for retrospective adverse or final adverse determinations.
G. The assignment by the Commissioner of an approved independent review organization to conduct an external review in accordance with this section shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the health care service that is the subject of the adverse determination or final adverse determination and other circumstances including conflict of interest concerns pursuant to subsection D of Section 6475.13 of this title. Added by Laws 2011, c. 278, § 43. Amended by Laws 2011, c. 360, § 33; Laws 2022, c. 154, § 16, eff. Nov. 1, 2022.