Continuation of Services

(1) If the subject matter of the expedited or non-expedited external review involves the termination of ongoing services, the insured or insured’s authorized representative may apply to the external review agency to seek the continuation of coverage for the terminated service during the period the review is pending. The insured or the insured’s representative should include, when applying, any evidence of a pattern of denials that have been overturned by prior internal or external review. Any such request to the external review agency must be made before the end of the second business day following receipt of the final adverse determination, or when the internal and external reviews are filed simultaneously, the second business day following receipt of the adverse determination. The external review agency shall order the continuation of coverage or treatment where it determines that substantial harm to the insured’s health may result absent such continuation or for such other good cause as the external review agency shall determine, which shall include, but not be limited to, a pattern of denials that have been overturned by prior internal or external reviews. Continuation of coverage shall be at the carrier’s expense regardless of the final external review determination. (2) A request for continuation of coverage by an insured or insured's authorized representative shall be included in the external review request, on the external review request form issued by the Office of Patient Protection. (3) If continuation of coverage was provided during the internal review process, then any continuation of coverage ordered during the external review shall follow immediately upon the prior coverage so that there is no gap in coverage between the internal review process and external review process.