§432E-35  Expedited external review. 

(a)  Except as provided in subsection (i), an enrollee or the enrollee's

appointed representative may request an expedited external review with the

commissioner if the enrollee receives:

     (1)  An adverse determination that involves a medical

condition of the enrollee for which the time frame for completion of an

expedited internal appeal would seriously jeopardize the enrollee's life,

health, or ability to gain maximum functioning or would subject the enrollee to

severe pain that cannot be adequately managed without the care or treatment

that is the subject of the adverse determination;

     (2)  A final adverse determination if the enrollee has

a medical condition where the time frame for completion of a standard external

review would seriously jeopardize the enrollee's ability to gain maximum

functioning, or would subject the enrollee to severe pain that cannot be

adequately managed without the care or treatment that is the subject of the

adverse determination; or

     (3)  A final adverse determination if the final

adverse determination concerns an admission, availability of care, continued

stay, or health care service for which the enrollee received emergency

services; provided that the enrollee has not been discharged from a facility

for health care services related to the emergency services.

     (b)  Upon receipt of a request for an expedited

external review, the commissioner shall immediately send a copy of the request

to the health carrier.  Immediately upon receipt of the request, the health

carrier shall determine whether the request meets the reviewability

requirements set forth in subsection (a).  The health carrier shall immediately

notify the enrollee or the enrollee's appointed representative of its

determination of the enrollee's eligibility for expedited external review.

     Notice of ineligibility for expedited external

review shall include a statement informing the enrollee and the enrollee's

appointed representative that a health carrier's initial determination that an

external review request that is ineligible for review may be appealed to the

commissioner by submission of a request to the commissioner.

     (c)  Upon receipt of a request for appeal

pursuant to subsection (b), the commissioner shall review the request for expedited

external review submitted pursuant to subsection (a) and, if eligible, shall

refer the enrollee for external review.  The commissioner's determination of

eligibility for expedited external review shall be made in accordance with the

terms of the enrollee's health benefit plan and all applicable provisions of

this part.  If an enrollee is not eligible for expedited external review, the

commissioner shall immediately notify the enrollee, the enrollee's appointed

representative, and the health carrier of the reasons for ineligibility.

     (d)  If the commissioner determines that an

enrollee is eligible for expedited external review even though the enrollee has

not exhausted the health carrier's internal review process, the health carrier

shall not be required to proceed with its internal review process.  The health

carrier may elect to proceed with its internal review process even though the

request is determined by the commissioner to be eligible for expedited external

review; provided that the internal review process shall not delay or terminate

an expedited external review unless the health carrier decides to reverse its

adverse determination and provide coverage or payment for the health care

service that is the subject of the adverse determination.  Immediately after

making a decision to reverse its adverse determination, the health carrier

shall notify the enrollee, the enrollee's authorized representative, the

independent review organization assigned pursuant to subsection (e), and the

commissioner in writing of its decision.  The assigned independent review

organization shall terminate the expedited external review upon receipt of

notice from the health carrier pursuant to this subsection.

     (e)  Upon receipt of the notice pursuant to

subsection (b) or a determination of the commissioner pursuant to subsection (d)

that the enrollee meets the eligibility requirements for expedited external

review, the commissioner shall immediately randomly assign an independent

review organization to conduct the expedited external review from the list of

approved independent review organizations qualified to conduct the external

review, based on the nature of the health care service that is the subject of

the adverse action and other factors determined by the commissioner including

conflicts of interest pursuant to section 432E-43, compiled and maintained by

the commissioner to conduct the external review and immediately notify the

health carrier of the name of the assigned independent review organization.

     (f)  Upon receipt of the notice from the

commissioner of the name of the independent review organization assigned to

conduct the expedited external review, the health carrier or its designee

utilization review organization shall provide or transmit all documents and information

it considered in making the adverse action that is the subject of the expedited

external review to the assigned independent review organization electronically

or by telephone, facsimile, or any other available expeditious method.

     (g)  In addition to the documents and

information provided or transmitted pursuant to subsection (f), the assigned

independent review organization shall consider the following in reaching a

decision:

     (1)  The enrollee'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 carrier, enrollee,

the enrollee's appointed representative, or the enrollee's treating provider;

     (4)  The application of medical necessity criteria as

defined in section 432E-1;

     (5)  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, and associations;

     (6)  Any applicable clinical review criteria developed

and used by the health carrier or its designee utilization review organization

in making adverse determinations; and

     (7)  The opinion of the independent review

organization's clinical reviewer or reviewers pertaining to the information

enumerated in paragraphs (1) through (5) to the extent the information and

documents are available and the clinical reviewer or reviewers consider

appropriate.

     In reaching a decision, the assigned

independent review organization shall not be bound by any decisions or

conclusions reached during the health carrier's utilization review or internal

appeals process; provided that the independent review organization's decision

shall not contradict the terms of the enrollee's health benefit plan or this

part.

     (h)  As expeditiously as the enrollee'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 (a), the

assigned independent review organization shall:

     (1)  Make a decision to uphold or reverse the adverse

action; and

     (2)  Notify the enrollee, the enrollee's appointed

representative, the health carrier, and the commissioner of the decision.

     If the notice provided pursuant to this

subsection was not in writing, within forty-eight hours after the date of

providing that notice, the assigned independent review organization shall

provide written confirmation of the decision to the enrollee, the enrollee's

appointed representative, the health carrier, and the commissioner that

includes the information provided in section 432E-37.

     Upon receipt of the notice of a decision

reversing the adverse action, the health carrier shall immediately approve the

coverage that was the subject of the adverse action.

     (i)  An expedited external review shall not be

provided for retrospective adverse or final adverse determinations. [L 2011, c

230, pt of §2; am L 2012, c 34, §12]