§ 22:2436 — Standard external review

§2436. Standard external review
A. Within four months after the date of receipt of a notice of an adverse
determination or final adverse determination pursuant to R.S. 22:2433, a covered person or
his authorized representative may file a request for an external review with the health
insurance issuer, regardless of the claim amount.
B. Within five business days following the date of receipt of the external review
request from the covered person or his authorized representative pursuant to Subsection A
of this Section, the health insurance issuer shall complete a preliminary review of the request
to determine whether all of the following have been met:
(1) The individual is or was a covered person in the health benefit plan at the time
the health care service was requested or, in the case of a retrospective review, was a covered
person in the health benefit plan at the time the health care service was provided.
(2) The health care service is the subject of an adverse determination or a final
adverse determination.
(3) The covered person has exhausted the health insurance issuer's internal claims
and appeals process as provided pursuant to R.S. 22:2401 unless the covered person is not
required to exhaust the health insurance issuer's internal claims and appeals process pursuant
to R.S. 22:2435.
(4) The covered person has provided all the information and forms required to
process an external review, including the authorization form provided for in R.S. 22:2433(B).
C.(1) Within the five business days allowed for the completion of the preliminary
review, the health insurance issuer shall notify the commissioner as provided pursuant to
Subsection D of this Section and notify the covered person and, if applicable, his authorized
representative of all the following, in writing, whether:
(a) The request is complete.
(b) The request is eligible for external review.
(2) If the request:
(a) Is not complete, the health insurance issuer shall inform the covered person and,
if applicable, his authorized representative in writing and state with specificity in the notice
the information or materials needed to make the request complete.
(b) Is not eligible for external review, the health insurance issuer shall inform the
covered person and, if applicable, his authorized representative in writing and include in the
notice the reasons for its ineligibility.
(3)(a) The commissioner may specify the form and method for the health insurance
issuer's notice of initial determination pursuant to Paragraph (2) of this Subsection and any
supporting information to be included in the notice.
(b) The notice of initial determination pursuant to Paragraph (2) of this Subsection
shall include a statement informing the covered person and, if applicable, his authorized
representative that a health insurance issuer's initial determination that the external review
request is ineligible for review may be appealed to the commissioner.
(4)(a) If the covered person or his authorized representative makes a written request
to the commissioner of insurance after the receipt of the denial of an external review, the
commissioner may determine that a request is eligible for external review pursuant to
Subsection B of this Section, notwithstanding a health insurance issuer'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 all applicable provisions of this
Part.
(c) The commissioner shall notify the health insurance issuer and the covered person
or his authorized representative of his determination about the eligibility of the request within
five business days of the receipt of the request from the covered person. Within one business
day of receipt of the commissioner's determination that a request is eligible for an external
review, a health insurance issuer shall comply with Subsection D of this Section.
D.(1) A health insurance issuer shall notify the commissioner that a request is
eligible for external review pursuant to Subsection C of this Section by submitting a request
for assignment of an independent review organization through the Department of Insurance's
website. Upon notification, the commissioner shall do the following:
(a) Randomly assign an independent review organization from the list of approved
independent review organizations compiled and maintained by the commissioner pursuant
to R.S. 22:2440 to conduct the external review and notify the health insurance issuer of the
name of the assigned independent review organization.
(b) Within one business day, send written notice to the covered person and, if
applicable, his authorized representative, of the request's eligibility and acceptance for
external review and the identity and contact information of the assigned independent review
organization.
(2) A health insurance issuer shall notify the commissioner in a manner prescribed
by the department if a request is determined not complete pursuant to Subsection C of this
Section, and the notice shall state with specificity the information or materials needed to
make the request complete. If a form required by a health insurance issuer has not been
completed, the health insurance issuer shall include in the notice a copy of the form, and
copies of any materials submitted by the covered person or, if applicable, his authorized
representative that could reasonably be interpreted as pertaining to the same subject matter
or purpose of the form. Any notice or form required to be provided by this Paragraph may
be provided electronically on the department's website.
(3) In reaching a decision, the assigned independent review organization shall not
be bound by any decisions or conclusions reached during the health insurance issuer's
internal claims and appeals process as provided pursuant to R.S. 22:2401.
(4) The commissioner shall include in the notice provided to the covered person and,
if applicable, his authorized representative a statement that the covered person or his
authorized representative may submit in writing to the assigned independent review
organization, within five business days following the date of receipt of the notice provided
pursuant to Subparagraph (1)(b) of this Subsection, additional information that the
independent review organization shall consider when conducting the external review. The
independent review organization shall be authorized but not required to accept and consider
additional information submitted after five business days.
E.(1) Within five business days after the date of receipt of the notice provided
pursuant to Subparagraph (D)(1)(b) of this Section, the health insurance issuer or its
utilization review organization shall provide to the assigned independent review organization
the documents and any information considered in making the adverse determination or final
adverse determination.
(2)(a) If a health insurance issuer or its utilization review organization fails to
provide the documents and information within the timeframe specified in Paragraph (1) of
this Subsection, the assigned independent review organization may terminate the external
review process and make a decision to reverse the adverse determination or the final adverse
determination. This Paragraph shall not apply if the issuer's failure to provide documents or
information is due to the covered person's failure to provide a signed form authorizing the
issuer to proceed with an external review or to release the insured's personal health
information to the independent review organization as required by federal law.
(b) Within one business day after making the decision pursuant to Subparagraph (a)
of this Paragraph, the independent review organization shall notify the covered person in
writing, if applicable, his authorized representative, the health insurance issuer, and the
commissioner.
(3) Repealed by Acts 2022, No. 81, §2, eff. Jan. 1, 2023.
F.(1) The assigned independent review organization shall review all of the
information and documents received pursuant to Subsection E of this Section and any other
information timely submitted in writing to the independent review organization by the
covered person or his authorized representative pursuant to Paragraph (D)(3) of this Section.
(2) Upon receipt of any information submitted by the covered person or his
authorized representative pursuant to Paragraph (D)(3) of this Section, the assigned
independent review organization shall, within one business day, forward the information to
the health insurance issuer.
G.(1) Upon receipt of the information, if any, required to be forwarded pursuant to
Paragraph (F)(2) of this Section, the health insurance issuer may reconsider its adverse
determination or final adverse determination that is the subject of the external review.
(2) Reconsideration by the health insurance issuer of its adverse determination or
final adverse determination pursuant to Paragraph (1) of this Subsection shall not delay or
terminate the external review.
(3) The external review may be terminated only if the health insurance issuer
decides, upon completion of its reconsideration, to reverse its adverse determination or final
adverse determination and provide coverage or payment for the health care service that is the
subject of the adverse determination or final adverse determination.
(4)(a) Within one business day after making the decision to reverse its adverse
determination or final adverse determination, as provided in Paragraph (3) of this Subsection,
the health insurance issuer shall notify the covered person, if applicable, his authorized
representative, the assigned independent review organization, and the commissioner in
writing of its decision.
(b) The assigned independent review organization shall terminate the external review
upon receipt of the notice from the health insurance issuer sent pursuant to Subparagraph (a)
of this Paragraph.
H. In addition to the documents and information provided pursuant to Subsection E
of this Section, the assigned independent review organization, to the extent that the
information or documents are available, shall consider the following in reaching a decision:
(1) The covered person's 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 insurance issuer, covered person, his 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 insurance issuer 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 insurance issuer.
(5) The most appropriate practice guidelines, which shall include applicable
evidence-based standards and may include any other practice guidelines developed by the
federal government or national or professional medical societies, boards, and associations.
(6) Any applicable clinical review criteria developed and used by the health
insurance issuer or its designee utilization review organization.
(7) The opinion of the independent review organization's clinical peer or peers after
considering Paragraphs (1) through (6) of this Subsection to the extent the information or
documents are available and the clinical peer or peers consider appropriate.
I.(1) Within forty-five days after the date of receipt of the request for an external
review, the assigned independent review organization shall provide written notice of its
decision to uphold or reverse the adverse determination or the final adverse determination
to each of the following:
(a) The covered person.
(b) If applicable, the covered person's authorized representative.
(c) The health insurance issuer.
(d) The commissioner.
(2) The independent review organization shall include the following in the notice
sent pursuant to Paragraph (1) of this Subsection:
(a) A general description of the reason for the request for external review.
(b) The date that the independent review organization received the assignment from
the commissioner to conduct the external review.
(c) The date that the external review was conducted.
(d) The date of its decision.
(e) The principal reason or reasons for its decision, including what applicable
evidence-based standards, if any, were a basis for its decision.
(f) The rationale for its decision.
(g) References to the evidence or documentation, including the evidence-based
standards, considered in reaching its decision.
(3) Upon receipt of a notice of a decision made pursuant to Paragraph (1) of this
Subsection reversing the adverse determination or final adverse determination, the health
insurance issuer shall immediately approve the coverage or payment that was the subject of
the adverse determination or final adverse determination.
J. 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 R.S. 22:2441(D).

Legislative History

Acts 2013, No. 326, §1, eff. Jan. 1, 2015; Acts 2022, No. 81, §§1, 2, eff. Jan. 1, 2023.