(a)Within three business days of receipt of notice from the department of assignment of the application for determination to an independent review organization, the managed care entity shall submit to that organization the following:
(1)Any information submitted to the managed care entity by the eligible enrollee in support of the eligible enrollee's grievance procedure filing;
(2)A copy of the contract provisions or evidence of coverage of the managed care plan; and (3) Any other relevant documents or information used by the managed care entity in determining the outcome of the eligible enrollee's grievance. Upon request, the managed care entity shall provide a copy of all documents required by this subsection, except for any proprietary or privileged information, to the eligible enrol
Free access — add to your briefcase to read the full text and ask questions with AI
(a) Within three business days of receipt of notice from the department of assignment of the application for determination to an independent review organization, the managed care entity shall submit to that organization the following: (1) Any information submitted to the managed care entity by the eligible enrollee in support of the eligible enrollee's grievance procedure filing; (2) A copy of the contract provisions or evidence of coverage of the managed care plan; and (3) Any other relevant documents or information used by the managed care entity in determining the outcome of the eligible enrollee's grievance. Upon request, the managed care entity shall provide a copy of all documents required by this subsection, except for any proprietary or privileged information, to the eligible enrollee. The eligible enrollee may provide the independent review organization with any additional information the eligible enrollee deems relevant. (b) The independent review organization shall request any additional information required for the review from the managed care entity and the eligible enrollee within five business days of receipt of the documentation required under this Code section. Any additional information requested by the independent review organization shall be submitted within five business days of receipt of the request, or an explanation of why the additional information is not being submitted shall be provided. (c) Additional information obtained from the eligible enrollee shall be transmitted to the managed care entity, which may determine that such additional information justifies a reconsideration of the outcome of the grievance procedure. A decision by the managed care entity to cover fully the treatment in question upon reconsideration using such additional information shall terminate independent review. (d) The expert reviewer of the independent review organization shall make a determination within 15 business days after expiration of all time limits set forth in this Code section, but such time limits may be extended or shortened by mutual agreement between the eligible enrollee and the managed care entity. The determination shall be in writing and state the basis of the reviewer's decision. A copy of the decision shall be delivered to the managed care entity, the eligible enrollee, and the department by at least first-class mail. (e) The independent review organization's decision shall be based upon a review of the information and documentation submitted to it. (f) Information required or authorized to be provided pursuant to this Code section may be provided by facsimile transmission or other electronic transmission.