A.For a group health plan, or a grandfathered individual plan, if a health care insurer elects to include as part of its internal review levels a voluntary internal appeal level after any applicable initial appeal pursuant to section 20-2535 and the utilization review agent denies the member's initial request, the member may appeal that adverse determination to the voluntary internal appeal level. The member shall send a written appeal to the utilization review agent within sixty days after receipt of the adverse determination.
B.The member or the member's treating provider shall submit to the utilization review agent with the written voluntary internal appeal any material justification or documentation to support the member's request for the service or claim for a service.
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A. For a group health plan, or a grandfathered individual plan, if a health care insurer elects to include as part of its internal review levels a voluntary internal appeal level after any applicable initial appeal pursuant to section 20-2535 and the utilization review agent denies the member's initial request, the member may appeal that adverse determination to the voluntary internal appeal level. The member shall send a written appeal to the utilization review agent within sixty days after receipt of the adverse determination.
B. The member or the member's treating provider shall submit to the utilization review agent with the written voluntary internal appeal any material justification or documentation to support the member's request for the service or claim for a service.
C. If the member's appeal involves an issue of medical necessity or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the coverage document and not whether the service is covered, the utilization review agent shall select a provider to review the appeal and render a determination based on the utilization review plan adopted by the utilization review agent. For the purposes of this subsection:
1. "Advanced practice registered nurse" means any of the following as defined in section 32-1601:
(a) A certified nurse midwife.
(b) A certified registered nurse anesthetist.
(c) A clinical nurse specialist.
(d) A registered nurse practitioner.
2. "Provider" means either of the following:
(a) A physician or other health care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15, who is qualified in a similar scope of practice as a physician or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15 and who is employed or under contract with the utilization review agent.
(b) An out-of-state physician or other health care professional who is licensed in another state and who is not licensed in this state, who is employed or under contract with the utilization review agent and who either is qualified in a similar scope of practice as a physician or other health care professional Licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15 or who typically manages the medical condition under appeal.
D. Except as provided in subsection E of this section, the utilization review agent shall send to the member and the member's treating provider a notice of the utilization review agent's determination and the basis, criteria used, clinical reasons and rationale for that determination within the time frames prescribed in section 20-2533, subsection D.
E. At any time during the voluntary internal appeal process, the utilization review agent may request an external independent review process pursuant to section 20-2537. If the utilization review agent initiates the external independent review process, the utilization review agent does not have to comply with subsection d of this section.
F. If at the conclusion of the voluntary internal appeal process the utilization review agent denies the appeal and the utilization review agent does not initiate the external independent review process, the utilization review agent shall provide the member with notice of the option to proceed to an external independent review pursuant to section 20-2537.
G. If the utilization review agent concludes that the covered service should be provided or the claim for a covered service should be paid, the health care insurer is bound by the utilization review agent's determination.