§ 31-3875.05 — Appeals.

District of Columbia § 31-3875.05

• Jurisdiction: District of Columbia
• Title 31: Insurance and Securities.
• Ch. 38F: Prior Authorization by a Utilization Review Entity.

Text

(a) A utilization review entity shall provide an enrollee with at least 15 calendar days from the date the enrollee receives notice of an adverse determination to appeal the decision via the utilization review entity's website, facsimile, or mail; provided, that an appeal submitted by mail shall be considered timely if postmarked within 15 calendar days of the enrollee receiving notice.

(b) In reviewing an appeal, the utilization review entity shall consider all known clinical aspects of the health care service under review, including a review of all pertinent medical records, other relevant records, and any medical literature provided by the enrollee, representative, or the enrollee's health care provider.

(c) The enrollee, representative, and the enrollee's health care provider shall be notified within 24 hours of the utilization review entity making a decision on the appeal, which shall include the following information:

(1) The qualifications of the physician reviewing the appeal including:

(A) States in which the physician is licensed;

(B) Status of their medical licenses;

(C) Their medical specialty; and

(D) Years of practice in that specialty; and

(2) The grounds for the physician's decision under the utilization review entity's prior authorization requirements.