Review of Internal Grievances

(1) Each reviewer assigned by a carrier or utilization review organization to perform review of an internal grievance must meet the following qualifications: (a) Each reviewer shall not have participated in any of the carrier's prior decisions regarding the treatment or service at issue in the grievance, and shall not be subordinate to or under the supervision of the reviewer who issued the adverse determination. (b) Each reviewer shall have no conflict of interest, such that decisions by the carrier or utilization review organization regarding the hiring, compensation, termination, promotion, or other similar matters with respect to the reviewer must not be based upon the likelihood that the reviewer will support the denial of benefits. (2) Where the grievance was the result of an adverse determination, each reviewer shall be an actively practicing health care professional in the same or similar specialty and shall typically treat the medical condition, perform the procedure or provide the treatment that is the subject of the grievance. (3) The carrier shall assemble a medical record that is sufficiently complete such that the carrier or utilization review organization is able to conduct a full and fair review of the grievance.