§2437. Expedited external review
A. Except as provided in Subsection F of this Section, a covered person or his
authorized representative may make a request regardless of the claim amount for an
expedited external review with the health insurance issuer at the time that the covered person
receives:
(1)An adverse determination if both of the following apply:
(a)The adverse determination involves a medical condition of the covered person
for which the time frame for completion of an expedited internal review of a grievance
involving an adverse determination made pursuant to R.S. 22:2401 would seriously
jeopardize the life or health of the covered person or would jeopardize the covered person's
ability to regain maximum function.
(b)The covered person or his authorized representative has
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§2437. Expedited external review
A. Except as provided in Subsection F of this Section, a covered person or his
authorized representative may make a request regardless of the claim amount for an
expedited external review with the health insurance issuer at the time that the covered person
receives:
(1) An adverse determination if both of the following apply:
(a) The adverse determination involves a medical condition of the covered person
for which the time frame for completion of an expedited internal review of a grievance
involving an adverse determination made pursuant to R.S. 22:2401 would seriously
jeopardize the life or health of the covered person or would jeopardize the covered person's
ability to regain maximum function.
(b) The covered person or his authorized representative has filed a request for an
expedited review of a grievance involving an adverse determination made pursuant to R.S.
22:2401.
(2) A final adverse determination if either of the following applies:
(a) The covered person has a medical condition in which the time frame for
completion of a standard external review pursuant to R.S. 22:2436 would seriously
jeopardize the life or health of the covered person or would jeopardize the covered person's
ability to regain maximum function.
(b) The final adverse determination concerns an admission, availability of care,
continued stay, or health care service for which the covered person received emergency
services, but has not been discharged from a facility.
B.(1) Immediately upon receipt of the request pursuant to Subsection A of this
Section, the health insurance issuer shall determine whether the request meets the
reviewability requirements specified in R.S. 22:2436(B). The health insurance issuer shall
immediately notify the covered person and, if applicable, his authorized representative of its
eligibility determination.
(2)(a) The commissioner may specify the form and method for the health insurance
issuer's notice of initial determination pursuant to Paragraph (1) of this Subsection and any
supporting information to be included in the notice.
(b) The notice of initial determination pursuant to Paragraph (1) 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 an expedited external
review request is ineligible for review may be appealed to the commissioner.
(3)(a) If the covered person or his authorized representative makes a written request
to the commissioner of insurance after receipt of the notice of denial of an expedited external
review, the commissioner may determine that a request is eligible for an expedited external
review in accordance with the criteria found in R.S. 22:2436(B), 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 immediately notify the health insurance issuer and the
covered person or his authorized representative of its determination about the eligibility of
the request. Following receipt of the commissioner's determination that a request is eligible
for an expedited external review, a health insurance issuer shall immediately comply with
Paragraph (4) of this Subsection.
(4) Immediately upon the health insurance issuer's determination that a request is
eligible for an expedited external review or upon the determination by the commissioner that
a request is eligible for an expedited external review, the health insurance issuer shall submit
a request for assignment of an independent review organization through the Department of
Insurance's website. Upon receipt of the notice that the request meets the reviewability
requirements, the commissioner shall immediately assign an independent review
organization to conduct the expedited external review from the list of approved independent
review organizations compiled and maintained by the commissioner pursuant to R.S.
22:2440. The commissioner shall immediately notify the health insurance issuer and the
covered person or his authorized representative of the name and contact information of the
assigned independent review organization.
(5) In reaching a decision in accordance with Subsection E of this Section, the
assigned independent review organization is not bound by any decisions or conclusions
reached during the health insurance issuer's utilization review process or the health insurance
issuer's internal claims and appeals process provided pursuant to R.S. 22:2401.
C.(1) Upon receipt of the notice from the commissioner of the name of the
independent review organization assigned to conduct the expedited external review pursuant
to Paragraph (B)(4) of this Section, the health insurance issuer or its designee utilization
review organization shall provide or transmit all necessary documents and information
considered in making the adverse determination or final adverse determination to the
assigned independent review organization electronically, by telephone or facsimile, or by any
other available expeditious method.
(2) Any information required by Paragraph (1) of this Subsection and not received
from a health insurance issuer as expeditiously as is necessary for consideration in reaching
a decision required in Subsection E of this Section shall be presumed to include the
information that is the most favorable to a covered person in reaching a decision required in
Subsection E of this Section.
D. In addition to the documents and information provided or transmitted pursuant
to Subsection C of this Section, the assigned independent review organization, to the extent
the information or documents are available, shall consider the following in reaching a
decision:
(1) The covered person's pertinent 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, the 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 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 in making adverse
determinations.
(7) The opinion of the independent review organization's clinical peer or peers after
considering the information specified by Paragraphs (1) through (6) of this Subsection to the
extent the information and documents are available and the clinical peer or peers consider
appropriate.
E.(1) As expeditiously as the covered person's medical condition or circumstances
requires, but in no event more than seventy-two hours after the date that the health insurance
issuer receives the request for an expedited external review, the assigned independent review
organization shall do both of the following:
(a) Make a decision to uphold or reverse the adverse determination or final adverse
determination.
(b) Notify the covered person, his authorized representative, if applicable, the health
insurance issuer, and the commissioner of the decision.
(2) If the notice provided pursuant to Paragraph (1) of this Subsection was not in
writing, within forty-eight hours after the date of providing that notice, the assigned
independent review organization shall do both of the following:
(a) Provide written confirmation of the decision to the covered person, his authorized
representative, if applicable, the health insurance issuer, and the commissioner.
(b) Include the information specified in R.S. 22:2436(I)(2).
(3) Upon receipt of the notice of a decision pursuant to Paragraph (1) of this
Subsection reversing the adverse determination or final adverse determination, the health
insurance issuer shall immediately approve the coverage that was the subject of the adverse
determination or final adverse determination.
F. An expedited external review shall not be provided for retrospective adverse
determinations or retrospective final adverse determinations.
G. The assignment by the commissioner of an approved independent review
organization to conduct an expedited 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 expedited 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).