§ 38-71-1970 — Requests for external review.

(A)(1) Within sixty days after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to Section 38-71-1940, a covered person or his authorized representative may file a request for an external review with the health carrier. (2) If the denial of coverage is based on a determination that the health care service or treatment recommended or requested is experimental or investigational, the request for review must include a certification from the covered person's treating physician who must be a licensed physician qualified to practice in the area of medicine appropriate to treat the covered person's condition that: (a) the covered person has a life-threatening disease or seriously disabling condition; and (b) at least one of the following situations is applicable: (i) standard health care services or treatments have not been effective in improving the condition of the covered person; (ii) standard health care services or treatments are not medically appropriate for the covered person; or (iii) the recommended or requested service or treatment is more beneficial than the standard health care service or treatment covered by the health carrier; and (c) medical and scientific evidence using accepted protocols demonstrate that the health care service or treatment requested by the covered person that is the subject of the adverse determination or final adverse determination is more beneficial to the covered person than available standard health care services or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of the standard services or treatments. (B)(1) Within five business days from the date the health carrier receives a request for an external review, the health carrier or its designee shall: (a) assign an independent review organization from the list of approved independent review organizations compiled and maintained pursuant to Section 38-71-2000 to conduct an external review; and (b) send the documents and any information considered in making the adverse determination or final adverse determination to the independent review organization; or (c) inform the covered person or his authorized representative in writing that the request does not meet the criteria for external review pursuant to this article and include a statement explaining the reason for nonacceptance and the right of the covered person to contact the director or his designee for assistance. The statement shall include the telephone number and address of the director or his designee; (2) Except as provided in item (3), failure by the health carrier or its designee to send the documents and information within the time specified in item (1) may not delay the conduct of the external review. (3)(a) If the health carrier or its designee fails to send the documents and information within the time specified in item (1), the independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination. (b) Immediately upon making the decision under item (3)(a), the independent review organization shall notify the covered person or his authorized representative and the health carrier. (C)(1) Within five business days after receipt of the request for external review from the health carrier, the independent review organization shall determine whether all the information, certifications, and forms required to process an external review, including the release form provided under Section 38-71-1940(B)(3) have been provided. The independent review organization shall immediately notify the covered person or his authorized representative in writing if additional information is required. (2) The independent review organization shall include in the notice provided pursuant to item (1) a clear statement that the covered person or his authorized representative may submit in writing to the independent review organization within seven business days following the date of receipt of the notice additional information and supporting documentation that the independent review organization shall consider when conducting the external review. (3) If the request is not: (a) complete, the independent review organization shall inform the covered person or his authorized representative what information or materials are needed to make the request complete; or (b) accepted for external review, the independent review organization shall inform the covered person or his authorized representative and the health carrier in writing of the reasons for its nonacceptance. (D)(1) If a request for external review is accepted for external review, the independent review organization shall notify the health carrier and the covered person or his authorized representative. (2) In reaching a decision, the independent review organization is not bound by any decisions or conclusions reached during the health carrier's utilization review process, as set forth in Chapter 70, or the health carrier's internal appeal process. (3) If the denial of coverage is based on a determination that the health care service or treatment recommended or requested is experimental or investigational, at the time a request is accepted for external review pursuant to subsection (C)(3), (a) the independent review organization shall: (i) immediately select a clinical peer review panel pursuant to subitem (b) to conduct the external review; and (ii) based on the opinions of the clinical peer reviewers on the panel, make a decision to uphold or reverse the adverse determination or final adverse determination. (b)(i) Notwithstanding the provisions of subsubitem (ii), the panel shall consist of the number of physicians or other health care professionals considered appropriate by the independent review organization who meet the minimum qualifications described in Section 38-71-2010 and, through clinical experience in the past three years, are experts in the treatment of the covered person's condition and knowledgeable about the recommended or requested health care service or treatment. (ii) The health carrier may require that the panel consist of at least three physicians or other health care professionals who meet the minimum qualifications described in Section 38-71-2010 and, through clinical experience in the past three years, are experts in the treatment of the covered person's condition and knowledgeable about the recommended or requested health care service or treatment. (iii) Neither the covered person nor his authorized representative, if applicable, nor the health carrier shall choose or control the choice of the physicians or other health care professionals to be selected for the clinical peer review panel. (c) Each member of the clinical peer review panel shall provide a written opinion to the independent review organization on whether to uphold or reverse the adverse determination or the final adverse determination. Each clinical peer reviewer's opinion shall include a description: (i) of the covered person's medical condition, which is the subject of the adverse determination or final adverse determination; (ii) of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is more beneficial to the covered person than standard services or treatments and that the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of the standard services or treatment; and (iii) analysis of the medical and scientific evidence used in making the determination. (E)(1) The independent review organization shall review all of the information and documents received from the health carrier and any other information submitted in writing to the independent review organization by the covered person or his authorized representative. (2) Upon receipt of any information submitted by the covered person or his authorized representative pursuant to subsection (C)(2), the independent review organization immediately shall forward the information to the health carrier. (F)(1) The health carrier may reconsider its adverse determination or final adverse determination at any time. (2) Reconsideration by the health carrier may not delay or terminate the external review. (3) The health carrier may terminate the external review only if the health carrier reverses its adverse determination or final adverse determination. (4)(a) within five business days of making the decision to reverse its adverse determination or final adverse determination, as provided in item (3), the health carrier shall send written notice to the covered person or his authorized representative and the independent review organization. (b) the independent review organization shall terminate the external review upon receipt of the notice from the health carrier sent pursuant to subitem (a). (G) In addition to the documents and information provided or transmitted pursuant to this section, the independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision: (1) the covered person's relevant medical records; (2) the treating health care provider's recommendation; (3) consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, his authorized representative, or the covered person's treating provider; (4) the most appropriate practice guidelines, which may include generally accepted practice guidelines, evidence-based practice guidelines, or any other practice guidelines developed by the federal government or national or professional medical societies, boards, and associations; (5) any applicable clinical review criteria developed and used by the health carrier or its designee; and (6) If adverse determination or final adverse determination involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, whether: (a) the recommended or requested health care service or treatment has been approved by the Federal Food and Drug Administration; or (b) medical and scientific evidence demonstrates that the expected benefits of the recommended or requested health care service or treatment would be greater than the benefits of any available standard service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of standard services or treatments. (H)(1) Within forty-five days after the date of receipt of the request for an external review by the health carrier, the independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to the covered person or his authorized representative and the health carrier. (2) If adverse determination or final adverse determination involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, the independent review organization shall make a decision to uphold or reverse the health carrier's adverse determination or final adverse determination based upon the recommendation of a majority of the clinical peer review panel, if more than one physician or other health care professional serves on the panel. (3) The independent review organization shall include in the notice sent pursuant to item (1): (a) a general description of the reason for the request for external review; (b) the date the independent review organization received the assignment from the health carrier; (c) the date the external review was conducted, if appropriate; (d) the date of its decision; (e) the principal reason or reasons for its decision; (f) the rationale for its decision; (g) references to the evidence or documentation, including the practice guidelines, considered in reaching its decision; and (h) the written opinions of the clinical peer review panel, if any. (4) Within five business days of receipt of a notice of a decision pursuant to item (1) reversing the adverse determination or final adverse determination, the health carrier shall approve the covered benefit that was the subject of the adverse determination or final adverse determination, subject to applicable contract exclusions, limitations, or other provisions. (I) The assignment by a health carrier of an approved independent review organization to conduct an external review in accordance with this section must be fair and impartial. The health carrier and the independent review organization shall comply with standards promulgated by the director or his designee by regulation or bulletin to ensure fairness and impartiality in the assignment by health carriers of approved independent review organizations to conduct external reviews, including its term, its termination, and payment arrangement.

Legislative History

HISTORY: 2000 Act No. 380, SECTION 3A.