(1)Except as provided in subsection (6) of this section,
a covered person or the covered person's authorized representative may make
a request for an expedited external review with the director at the time that
the covered person receives:
(a)An adverse determination
if:
(i)The adverse determination involves a medical condition of the covered person
for which the timeframe for completion of an expedited internal review of
a grievance involving an adverse determination set forth in section 44-7311
would seriously jeopardize the life or health of the covered person or would
jeopardize the covered person's ability to regain maximum function; and
(ii)The covered person
or the covered person's authorized representative has filed a request for
an expedited review of a grievance involving a
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(1) Except as provided in subsection (6) of this section,
a covered person or the covered person's authorized representative may make
a request for an expedited external review with the director at the time that
the covered person receives:
(a) An adverse determination
if:
(i)
The adverse determination involves a medical condition of the covered person
for which the timeframe for completion of an expedited internal review of
a grievance involving an adverse determination set forth in section 44-7311
would seriously jeopardize the life or health of the covered person or would
jeopardize the covered person's ability to regain maximum function; and
(ii) The covered person
or the covered person's authorized representative has filed a request for
an expedited review of a grievance involving an adverse determination as set
forth in section 44-7311 ; or
(b) A final adverse determination:
(i) If the covered person
has a medical condition in which the timeframe for completion of a standard
external review pursuant to section 44-1308 would seriously jeopardize the
life or health of the covered person or would jeopardize the covered person's
ability to regain maximum function; or
(ii) If 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.
(2)(a)
Upon receipt of a request for an expedited external review, the director shall
immediately send a copy of the request to the health carrier.
(b) Immediately upon receipt
of the request pursuant to subdivision (2)(a) of this section, the health
carrier shall determine whether the request meets the reviewability requirements
set forth in subsection (2) of section 44-1308 . The health carrier shall immediately
notify the director and the covered person and, if applicable, the covered
person's authorized representative of its eligibility determination.
(c)(i) The director may
specify the form for the health carrier's notice of initial determination
under this subsection and any supporting information to be included in the
notice.
(ii)
The notice of initial determination shall include a statement informing the
covered person and, if applicable, the covered person's authorized representative
that a health carrier's initial determination that an external review request
is ineligible for review may be appealed to the director.
(d)(i) The director may
determine that a request is eligible for external review under subsection
(2) of section 44-1308 notwithstanding a health carrier's initial determination
that the request is ineligible and require that it be referred for external
review.
(ii)
In making a determination under subdivision (2)(d)(i) of this section, the
director'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 the Health Carrier External Review Act.
(e) Upon receipt of the notice that the request meets
the reviewability requirements, the director 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
director pursuant to section 44-1312 . The director shall immediately notify
the health carrier of the name of the assigned independent review organization.
(f) In reaching a decision
in accordance with subsection (5) of this section, the assigned independent
review organization is not bound by any decisions or conclusions reached during
the health carrier's utilization review process as set forth in the Health
Carrier Grievance Procedure Act or the Utilization Review Act.
(3) Upon receipt of the
notice from the director of the name of the independent review organization
assigned to conduct the expedited external review pursuant to subdivision
(2)(e) of this section, the health carrier 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 or by telephone
or facsimile or any other available expeditious method.
(4) In addition to the
documents and information provided or transmitted pursuant to subsection (3)
of this section, the assigned independent review organization, to the extent
that 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 attending health care professional's
recommendation;
(c)
Consulting reports from appropriate health care professionals and other documents
submitted by the health carrier, covered person, the covered person's authorized
representative, or the covered person's treating provider;
(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 evidence-based
standards, and may include any other practice guidelines developed by the
federal government, national or professional medical societies, boards, or
associations;
(f)
Any applicable clinical review criteria developed and used by the health carrier
or its designee utilization review organization in making adverse determinations;
and
(g)
The opinion of the independent review organization's clinical reviewer or
reviewers after considering subdivisions (4)(a) through (f) of this section
to the extent that the information and documents are available and the clinical
reviewer or reviewers consider it appropriate.
(5)(a) As expeditiously as the covered
person's medical condition or circumstances requires, but in no event more
than seventy-two hours after the date of receipt of the request for an expedited
external review that meets the reviewability requirements set forth in subsection
(2) of section 44-1308 , the assigned independent review organization shall:
(i) Make a decision to
uphold or reverse the adverse determination or final adverse determination;
and
(ii)
Notify the covered person and, if applicable, the covered person's authorized
representative, the health carrier, and the director of the decision.
(b) If the notice provided
pursuant to subdivision (5)(a) of this section was not in writing, within
forty-eight hours after the date of providing that notice, the assigned independent
review organization shall:
(i)
Provide written confirmation of the decision to the covered person and, if
applicable, the covered person's authorized representative, the health carrier,
and the director; and
(ii)
Include the information set forth in subdivision (9)(b) of section 44-1308 .
(c) Upon receipt of the
notice of a decision pursuant to subdivision (5)(a) of this section 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.
(6) An expedited external review
may not be provided for retrospective adverse or final adverse determinations.
(7) The assignment by
the director 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 subsection (4) of section 44-1313 .