§ 24-A §4312 — Independent external review

An enrollee or the enrollee's authorized representative has the right to an independent external review of a carrier's adverse health care treatment decision made by or on behalf of a carrier offering or renewing a health plan in accordance with the requirements of this section. An enrollee's failure to obtain authorization prior to receiving an otherwise covered service may not preclude an enrollee from exercising the enrollee's rights under this section.
1.
Request for external review.
An enrollee or the enrollee's authorized representative shall make a written request for external review of an adverse health care treatment decision to the bureau. Except as provided in subsection 2, an enrollee may not make a request for external review under a group plan until the enrollee has exhausted all levels of a carrier's internal grievance procedure and may not make a request for external review under an individual plan until the enrollee has exhausted one level of a carrier's internal grievance procedure. A request for external review must be made within 12 months of the date an enrollee has received a final adverse health care treatment decision under a carrier's internal grievance procedure. An enrollee may not be required to pay any filing fee as a condition of processing a request for external review.
1-A.
Request for independent external review by enrollee's authorized representative.
A request for an independent external review may be made by an enrollee's authorized representative as defined in section 4301‑A, subsection 2, paragraph D in accordance with this subsection.
2.
Expedited request for external review.
An enrollee or an enrollee's authorized representative is not required to exhaust a carrier's internal grievance procedure in accordance with subsection 1 before filing a request for external review if:
3.
Notice to enrollees.
A carrier shall notify an enrollee of the enrollee's right to request an external review in large type and easy-to-read language in a conspicuous location on the written notice of an adverse health care treatment decision. The notice must include:
4.
Independent external review; bureau oversight.
The bureau shall oversee the external review process required under this section and shall contract with approved independent review organizations to conduct an external review and render an external review decision. At a minimum, an independent review organization approved by the bureau shall ensure the selection of qualified and impartial reviewers who are clinical peers with respect to the adverse health care treatment decision under review and who have no professional, familial or financial conflict of interest relating to a carrier, enrollee, enrollee's authorized representative or health care provider involved in the external review.
5.
Independent external review decision; timelines.
An external review decision must be made in accordance with the following requirements.
6.
Binding nature of decision.
An external review decision is binding on the carrier. An enrollee or the enrollee's authorized representative may not file a request for a subsequent external review involving the same adverse health care treatment decision for which the enrollee has already received an external review decision pursuant to this section. An external review decision made under this section is not considered final agency action pursuant to Title 5, chapter 375, subchapter 7.
7.
Funding.
A carrier against which a request for external review has been filed shall pay the cost of the independent external review to the bureau.
7-A.
Confidentiality.
Except as provided in this subsection, all records of the bureau or an independent review organization relating to an external review request or external review proceeding are confidential and not a public record under Title 1, chapter 13.
8.
Rules.
The bureau may adopt rules necessary to carry out the requirements of this section, including, without limitation, criteria for determining when multiple denials of benefits to the same enrollee for the same or similar reasons are considered the same adverse health care treatment decision. Notwithstanding the requirements of section 4309, rules adopted pursuant to this section are routine technical rules as defined in Title 5, chapter 375, subchapter II‑A.
9.
Rights.
This section may not be construed to remove or limit any legal rights or remedies of an enrollee or other person under state or federal law, including the right to file judicial actions to enforce rights.
10.
Applicability.
Decisions relating to the following health care services are subject to review pursuant to other review processes provided by applicable federal or state law and may not be reviewed pursuant to this section:

Legislative History

PL 1999, c. 742, §19 (NEW). PL 2007, c. 199, Pt. B, §17 (AMD). PL 2011, c. 364, §§31, 32 (AMD). PL 2013, c. 274, §1 (AMD). PL 2023, c. 680, Pt. A, §§8, 9 (AMD). PL 2023, c. 680, Pt. A, §10 (AFF). PL 2025, c. 348, §35 (AMD).