1.Notwithstanding section 514J.107, a covered person or the covered person’s
authorized representative may make an oral or written request to the commissioner for an
expedited external review at the time the covered person or the covered person’s authorized
representative receives any of the following:
a.An adverse determination that involves a medical condition of the covered person for
which the time frame for completion of an 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.
b.A final adverse determination that involves a medical condition where the time frame
9 EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS, §514J.108
for
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1. Notwithstanding section 514J.107, a covered person or the covered person’s
authorized representative may make an oral or written request to the commissioner for an
expedited external review at the time the covered person or the covered person’s authorized
representative receives any of the following:
a. An adverse determination that involves a medical condition of the covered person for
which the time frame for completion of an 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.
b. A final adverse determination that involves a medical condition where the time frame
9 EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS, §514J.108
for completion of a standard external review would seriously jeopardize the life or health
of the covered person or would jeopardize the covered person’s ability to regain maximum
function.
c. A final adverse determination that concerns an admission, availability of care,
continued stay, or health care service for which the covered person received emergency
services, and the covered person has not been discharged from a facility.
2. a. Upon receipt of a request for an expedited external review, the commissioner shall
immediately send written notice of the request to the health carrier.
b. Immediatelyuponreceiptofnoticeofarequestforexpeditedexternalreview,thehealth
carrier shall complete a preliminary review of the request to determine whether the request
meetstheeligibilityrequirementsforexternalreviewsetforthinsection514J.107, subsection
3, and this section.
c. The health carrier shall then immediately issue a notice of initial determination
informing the commissioner and the covered person or the covered person’s authorized
representative of its eligibility determination including a statement informing the covered
person or the covered person’s authorized representative of the right to appeal that
determination to the commissioner.
d. The commissioner may specify by rule the form required for the health carrier’s notice
of initial determination and any supporting information to be included in the notice.
3. The commissioner may determine that a request is eligible for expedited external
review, notwithstandingahealthcarrier’sinitialdeterminationthattherequestisnoteligible.
In making a determination, 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 this chapter. The commissioner shall make a determination pursuant to this
subsection as expeditiously as possible.
4. a. Upon receipt of notice from a health carrier that a request is eligible for expedited
external review or upon a determination by the commissioner that a request is eligible
for expedited external review, the commissioner shall immediately assign an independent
review organization from the list of approved independent review organizations maintained
by the commissioner to conduct the expedited external review. The commissioner shall
then immediately notify the health carrier and the covered person or the covered person’s
authorized representative of the name of the assigned independent review organization.
b. Theassignmentofanindependentrevieworganizationshallbedoneonarandombasis
among those approved independent review organizations qualified to conduct the particular
externalreviewbasedonthenatureofthehealthcareservicethatisthesubjectoftheadverse
determination or final adverse determination and other circumstances, including conflict of
interest concerns.
5. Upon receiving notice of the independent review organization assigned to conduct
the expedited external review, the health carrier shall provide or transmit all necessary
documents and information considered in making the adverse determination or final adverse
determination to the independent review organization electronically or by telephone or
facsimile or any other available expeditious method.
6. The independent review organization is not bound by any decisions or conclusions
reached during the health carrier’s internal grievance process. The independent review
organization shall consider the documents and information provided by the health carrier,
and 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:
a. The covered person’s pertinent medical records.
b. The treating health care professional’s recommendation.
c. Consulting reports from appropriate health care professionals and other documents
submitted by the health carrier, covered person or the covered person’s authorized
representative, or the covered person’s treating physician or other health care professional.
d. 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.
e. The most appropriate practice guidelines, which shall include applicable
§514J.108, EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS 10
evidence-based standards and may include any other practice guidelines developed by the
federal government, national or professional medical societies, boards, and associations.
f. Any applicable clinical review criteria developed and used by the health carrier.
g. The opinion of the independent review organization’s clinical reviewer after
considering the information or documents described in paragraphs “a” through “f” to the
extent the information or documents are available and the clinical reviewer considers them
relevant.
7. a. Asexpeditiouslyasthecoveredperson’smedicalconditionorcircumstancesrequire,
but in no event more than seventy-two hours after the date of receipt of an eligible request
for expedited external review, the assigned independent review organization shall do all of
the following:
(1) Make a decision to uphold or reverse the adverse determination or final adverse
determination of the health carrier.
(2) Notify the covered person or the covered person’s authorized representative, the
health carrier, and the commissioner of its decision.
b. If the notice given by the independent review organization pursuant to paragraph “a”
was not in writing, within forty-eight hours after providing that notice, the independent
review organization shall provide written confirmation of the decision to the covered person
or the covered person’s authorized representative, the health carrier, and the commissioner
that includes the information set forth in section 514J.107, subsection 13, paragraph “b”.
c. Upon receipt of the notice of decision by an independent review organization pursuant
to paragraph “a” reversing the adverse determination or final adverse determination, the
health carrier shall immediately approve the coverage that was the subject of the adverse
determination or final adverse determination.