§ 27-18.9-7. Internal appeal procedural requirements.
(a) Administrative and non-administrative appeals. The review agent shall conform to the following for the internal appeal of administrative
or non-administrative adverse benefit determinations:
(1) The review agent shall maintain and make available a written description of its appeal
procedures by which either the beneficiary or the provider of record may seek review
of determinations not to authorize healthcare services.
(2) The process established by each review agent may include a reasonable period within
which an appeal must be filed to be considered and that period shall not be less than
one hundred eighty (180) calendar days after receipt of the adverse benefit determination
notice.
(3) During the appeal, a review agent may utilize a reconsideration process in assessing
an adverse benefit determination. If utilized, the review agent shall develop a reasonable
reconsideration and appeal process, in accordance with this section. For non-administrative
adverse benefit determinations, the period for the reconsideration may not exceed
fifteen (15) days from the date the request for reconsideration or appeal is received.
The review agent shall notify the beneficiary and/or provider of the reconsideration
determination with the form and content described in § 27-18.9-6(b), as appropriate. Following the decision on reconsideration, the beneficiary and/or
provider shall have a period of forty-five (45) calendar days during which the beneficiary
and/or provider may request an appeal of the reconsideration decision and/or submit
additional information.
(4) Prior to a final internal appeal decision, the review agent must allow the claimant
to review the entire adverse determination and appeal file and allow the claimant
to present evidence and/or additional testimony as part of the internal appeal process.
(5) A review agent is only entitled to request and review information or data relevant
to the benefit determination and utilization review processes.
(6) The review agent shall maintain records of written adverse benefit determinations,
reconsiderations, appeals and their resolution, and shall provide reports as requested
by the office.
(7)(i) The review agent shall notify, in writing, the beneficiary and/or provider of record
of its decision on the administrative appeal in no case later than thirty (30) calendar
days after receipt of the request for the review of an adverse benefit determination
for pre-service claims, and sixty (60) days for post-service claims, commensurate
with 29 C.F.R. § 2560.503-1(i)(2)(ii) and (iii).
(ii) The review agent shall notify, in writing, the beneficiary and provider of record
of its decision on the non-administrative appeal as soon as practical considering
medical circumstances, but in no case later than thirty (30) calendar days after receipt
of the request for the review of an adverse benefit determination, inclusive of the
period to conduct the reconsideration, if any. The timeline for decision on appeal
is paused from the date on which the determination on reconsideration is sent to the
beneficiary and/or provider and restarted when the beneficiary and/or provider submits
additional information and/or a request for appeal of the reconsideration decision.
(8) The review agent shall also provide for an expedited appeal process for urgent and
emergent situations taking into consideration medical exigencies. Notwithstanding
any other provision of this chapter, each review agent shall complete the adjudication
of expedited appeals, including notification of the beneficiary and provider of record
of its decision on the appeal, not later than seventy-two (72) hours after receipt
of the claimant's request for the appeal of an adverse benefit determination.
(9) Benefits for an ongoing course of treatment cannot be reduced or terminated without
providing advance notice and an opportunity for advance review. The review agent or
healthcare entity is required to continue coverage pending the outcome of an appeal.
(10) A review agent may not disclose or publish individual medical records or any confidential
information obtained in the performance of benefit determination or utilization review
activities. A review agent shall be considered a third-party health insurer for the
purposes of § 5-37.3-6(b)(6) and shall be required to maintain the security procedures mandated in § 5-37.3-4(c).
(b) Non-administrative appeals. In addition to subsection (a) of this section, the utilization review agent shall
conform to the following for its internal appeals adverse benefit determinations:
(1) A claimant is deemed to have exhausted the internal claims appeal process when the
utilization review agent or healthcare entity fails to strictly adhere to all benefit
determination and appeal processes with respect to a claim. In this case the claimant
may initiate an external appeal or remedies under section 502(a) of the Employee Retirement
Income Security Act of 1974, 29 U.S.C. § 1001 et seq., or other state and federal law, as applicable.
(2) No reviewer under this section, who has been involved in prior reviews or in the adverse
benefit determination under appeal or who has participated in the direct care of the
beneficiary, may participate in reviewing the case under appeal.
(3) All internal-level appeals of utilization review determinations not to authorize a
healthcare service that had been ordered by a physician, dentist, or other provider
shall be made according to the following:
(i) The reconsideration decision of a non-administrative adverse benefit determination
shall not be made until the utilization review agent's professional provider with
the same licensure status as typically manages the condition, procedure, treatment,
or requested service under discussion has spoken to, or otherwise provided for, an
equivalent two-way, direct communication with the beneficiary's attending physician,
dentist, other professional provider, or other qualified professional provider responsible
for treatment of the beneficiary concerning the services under review.
(ii) A review agent who does not utilize a reconsideration process must comply with the
peer-review obligation described in subsection (b)(3)(i) of this section as part of
the appeal process.
(iii) When the appeal of any adverse benefit determination, including an appeal of a reconsideration
decision, is based in whole or in part on medical judgment, including determinations
with regard to whether a particular service, treatment, drug, or other item is experimental,
investigational, or not medically necessary or appropriate, the reviewer making the
appeal decision must be appropriately trained having the same licensure status as
the ordering provider or be a physician or dentist and be in the same or similar specialty
as typically manages the condition. These qualifications must be provided to the claimant
upon request.
(iv) The utilization review agency reviewer must document and sign their decisions.
(4) The review agent must ensure that an appropriately licensed practitioner or licensed
physician is reasonably available to review the case as required under this subsection
(b) and shall conform to the following:
(i) Each agency peer reviewer shall have access to and review all necessary information
as requested by the agency and/or submitted by the provider(s) and/or beneficiaries;
(ii) Each agency shall provide accurate peer review contact information to the provider
at the time of service, if requested, and/or prior to such service, if requested.
This contact information must provide a mechanism for direct communication with the
agency's peer reviewer; and
(iii) Agency peer reviewers shall respond to the provider's request for a two-way, direct
communication defined in this subsection (b) as follows:
(A) For a prospective review of non-urgent and non-emergent healthcare services, a response
within one business day of the request for a peer discussion;
(B) For concurrent and prospective reviews of urgent and emergent healthcare services,
a response within a reasonable period of time of the request for a peer discussion;
and
(C) For retrospective reviews, prior to the internal-level appeal decision.
(5) The review agency will have met the requirements of a two-way, direct communication,
when requested and/or as required prior to the internal level of appeal, when it has
made two (2) reasonable attempts to contact the attending provider directly. Repeated
violations of this section shall be deemed to be substantial violations pursuant to
§ 27-18.9-9 and shall be cause for the imposition of penalties under that section.
(6) For the appeal of an adverse benefit determination decision that a drug is not covered,
the review agent shall complete the internal-appeal determination and notify the claimant
of its determination:
(i) No later than seventy-two (72) hours following receipt of the appeal request; or
(ii) No later than twenty-four (24) hours following the receipt of the appeal request in
cases where the beneficiary is suffering from a health condition that may seriously
jeopardize the beneficiary's life, health, or ability to regain maximum function or
when a beneficiary is undergoing a current course of treatment using a non-formulary
drug.
(iii) And if approved on appeal, coverage of the non-formulary drug must be provided for
the duration of the prescription, including refills unless expedited then for the
duration of the exigency.
(7) The review agents using clinical criteria and medical judgment in making utilization
review decisions shall comply with the following:
(i) The requirement that each review agent shall provide its clinical criteria to OHIC
upon request;
(ii) Provide and use written clinical criteria and review procedures established according
to nationally accepted standards, evidence-based medicine and protocols that are periodically
evaluated and updated, or other reasonable standards required by the commissioner;
(iii) Establish and employ a process to incorporate and consider local variations to national
standards and criteria identified herein including without limitation, a process to
incorporate input from local participating providers; and
(iv) Updated description of clinical decision criteria to be available to beneficiaries,
providers, and the office upon request and readily available and accessible on the
healthcare entity or the review agent's website.
(8) The review agent shall maintain records of written, adverse benefit determination
reconsiderations and appeals to include their resolution, and shall provide reports
and other information as requested by the office.