23 CAR pt. 117, Appendix B. Model External Review Request Form

2 Appendix B Model External Review Request Form This EXTERNAL REVIEW REQUEST FORM must be filed with the External Review Division, Arkansas Insurance Commissioner 1200 West Third Street, Little Rock, AR 72201; within FOUR (4) MONTHS after receipt from your insurer of a denial of payment on a claim or request for coverage of a health care service or treatment. EXTERNAL REVIEW REQUEST FORM APPLICANT NAME ____________________________ Covered person/Patient Provider Authorized Representative COVERED PERSON/PATIENT INFORMATION Covered Person Name: ______________________________ Patient Name: ___________________________ Address:_______________________________________________________________________________ ______________________________________________________________________________________ Covered Person Phone #: Home (____)___________________ Work (____)________________________ INSURANCE INFORMATION Insurer/HMO Name:_________________________________________________________________________ Covered Person Insurance ID#:___________________________________________________________ Insurance Claim/Reference #: _____________________________________________________________ Insurer/HMO Mailing Address: _________________________________________________________ _____________________________________________________________________________________________ Insurer Telephone #: (_____)_________________________________________________________________ EMPLOYER INFORMATION ________________________________________________________________________ (_____)______________________________________________________ Is the health coverage you have through your employer a self-funded plan? ________. If you are not certain please check with your employer. Most self-funded plans are not eligible for external review. However, some self-funded plans may voluntarily provide external review, but may have different procedures. You should check with your employer. 3 HEALTH CARE PROVIDER INFORMATION Treating Physician/Health Care Provider: __________________________________________________ Address: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Contact Person: ___________________________Phone: ( ) _____________________________ Medical Record #:_____________________________________ REASON FOR HEALTH CARRIER DENIAL (Please check one) The health care service or treatment is not medically necessary. The health care service or treatment is experimental or investigational. SUMMARY OF EXTERNAL REVIEW REQUEST (Enter a brief description of the claim, the request for health care service or treatment that was denied, and/or attach a copy of the denial from your health carrier)* _____________________________________________________________________________________________ _____________________________________________________________________________________________ ______________ *You may also describe in your own words the health care service or treatment in dispute and why you are appealing this denial using the attached pages below. EXPEDITED REVIEW If you need a fast decision, you may request that your external appeal be handled on an expedited basis. To complete this request, your treating health care provider must fill out the attached form stating that a delay would seriously jeopardize the life or health of the patient or would jeopardize Is this a request for an expedited appeal? Yes _______ _ No _________ SIGNATURE AND RELEASE OF MEDICAL RECORDS rm and consent to the release of medical records. I, _______________________________, hereby request an external appeal. I attest that the information provided in this application is true and accurate to the best of my knowledge. I authorize by insurance company and my health care providers to release all relevant medical or treatment records to the independent review organization and the Arkansas Insurance Department. I understand that the independent review organization and the Arkansas Insurance Department will use this information to make a determination on my external appeal and that the information will be kept confidential and not be released to anyone else. This release is valid for one year. ____________________________________________ ______________ Signature of Covered Person (or legal representative)* Date *(Parent, Guardian, Conservator or Other Please Specify) APPOINTMENT OF AUTHORIZED REPRESENTATIVE (Fill out this section only if someone else will be representing you in this appeal.) You can represent yourself, or you may ask another person, including your treating health care provider, to act as your authorized representative. You may revoke this authorization at any time. I hereby authorize ___________________________________ to pursue my appeal on my behalf. ___________________________________________ __________________ 4 Signature of Covered Person (or legal representative)* Date *(Parent, Guardian, Conservator or Other Please Specify) Address of Authorized Representative: ________________________________________________________________ ________________________________________________________________ Phone #: Daytime (_______)__________________________ Evening (________)_________________________________ 5 HEALTH CARE SERVICE OR TREATMENT DECISION IN DISPUTE DESCRIBE IN YOUR OWN WORDS THE DISAGREEMENT WITH YOUR HEALTH CARRIER. INDICATE CLEARLY THE SERVICE(S) BEING DENIED AND THE SPECIFIC DATE(S) BEING DENIED. EXPLAIN WHY YOU DISAGREE. ATTACH ADDITIONAL PAGES IF NECESSARY AND INCLUDE AVAILABLE PERTINENT MEDICAL RECORDS, ANY INFORMATION YOU RECEIVED FROM YOUR HEALTH CARRIER CONCERNING THE DENIAL, ANY PERTINENT PEER LITERATURE OR CLINICAL STUDIES, AND ANY ADDITIONAL INFORMATION FROM YOUR PHYSICIAN/HEALTH CARE PROVIDER THAT YOU WANT THE INDEPENDENT REVIEW ORGANIZATION REVIEWER TO CONSIDER. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 6 WHAT TO SEND AND WHERE TO SEND IT PLEASE CHECK BELOW (NOTE: YOUR REQUEST WILL NOT BE ACCEPTED FOR FULL REVIEW UNLESS ALL FOUR (4) ITEMS BELOW ARE INCLUDED*) 1. YES, I have included this completed application form signed and dated. 2. YES, I have included a photocopy of my insurance identification card or other evidence showing that I am insured by the health insurance company named in this application; 3. YES**, I have enclosed the letter from my health carrier or utilization review company that states: (a) Their decision is final and that I have exhausted all internal review procedures; or (b) They have waived the requirement to exhaust all of the healt procedures. **You may make a request for external review without exhausting all internal review procedures under certain circumstances. You should contact the External Review Division, Arkansas Insurance Department, 1200 West Third Street, Little Rock, Arkansas 72201, phone: 1-800-282-9134. 4. YES, I have included a copy of my certificate of coverage or my insurance policy benefit booklet, which lists the benefits under my health benefit plan. *Call the Insurance Department at 1-800-282-9134 if you need help in completing this application or if you do not have one or more of the above items and would like information on alternative ways to complete your request for external review. If you are requesting a standard external review, send all paperwork to: External Review Division, Arkansas Insurance Department 1200 West Third Street, Little Rock, AR 72201. If you are requesting an expedited external review, call the Arkansas Insurance Department before sending your paperwork, and you will receive instructions on the quickest way to submit the application and supporting information. 7 CERTIFICATION OF TREATING HEALTH CARE PROVIDER NOTE TO THE TREATING HEALTH CARE PROVIDER Patients can request an external review when a health carrier has denied a health care service or course of treatment on the basis of a utilization review determination that the requested health care service or course of treatment appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested. The External Review Division of the Arkansas Insurance Department oversees external appeals. The standard external review process can take up to 45 days from the care provider certifies that adherence to the time frame for the standard external review would seriously jeopardize the life or health of the expedited external review must be completed at most within 72 hours. This form is for the purpose of providing the certification necessary to trigger expedited review. GENERAL INFORMATION Name of Treating Health Care Provider: __________________________________________________ Mailing Address: ___________________________________________________________________________________ ___________________________________________________________________________________ Phone Number: (_____)__________________ Fax Number: (_______)__________________________ Licensure and Area of Clinical Specialty: _________________________________________________ ________________________________________________________________________________________ Name of Patient: ___________________________________________________________________________ _______________________________________________________________ 8 CERTIFICATION I hereby certify that: I am a treating health care provider for ____________________________________ life or health of the patient or would jeopard requested health care service or course of treatment should be processed on an expedited basis. ____________________________________________ ____________________________________________ _______________________ Signature Date 9 PHYSICIAN CERTIFICATION EXPERIMENTAL/INVESTIGATIONAL DENIALS (To Be Completed by Treating Physician) that I have requested the authorization for a drug, device, procedure or therapy denied for coverage due to the insurance co investigational. I understand that in order for the covered person to obtain the right to an external review of this denial, as treating physician I must certify that the covered person meets certain requirements: following: (Please check all that apply) (NOTE: Requirements #1 - #3 below must all apply for the covered person to qualify for an external review). 1) The covered person has a terminal medical condition, life threatening condition, or a seriously debilitating condition. 2) The covered person has a condition that qualifies under one or more of the following: [please indicate which description(s) apply]: Standard health care services or treatments have not been effective in improving the covered Standard health care services or treatments are not medically appropriate for the covered person; or There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the requested or recommended health care service or treatment. 3) The health care service or treatment I have recommended and which has been denied, in my medical opinion, is likely to be more beneficial to the covered person than any available standard health care services or treatments. 4) The health care service or treatment recommended would be significantly less effective if not promptly initiated. Explain:_____________________________________________________________________________________ _____________________________________________________________________________________________ 5) It is my medical opinion based on scientifically valid studies using accepted protocols that the health care service or treatment requested by the covered person and which has been denied is likely to be more beneficial to the covered person than any available standard health care services or treatments. Explain: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 10 Please provide a description of the recommended or requested health care service or treatment that is the subject of the denial. (Attach additional sheets as necessary) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________ ____________________________ Date