Expedited External Review

Expedited External Review A. Except as provided in subsection F, a covered person or the covered person’s authorized representative may make a request for an expedited external review with the Commissioner at the time the covered person receives: 1. An adverse determination if: a. The adverse determination involves a medical condition of the covered person for which the timeframe for completion of an expedited internal review of a grievance involving an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function; and b. The covered person or the covered person’s authorized representative has filed a request for an expedited review of a grievance involving an adverse determination; or 2. A final adverse determination: a. If the covered person has a medical condition where the timeframe for completion of a standard external review pursuant to Rule 15.07 of this Regulation would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function; or b. If the final adverse determination concerns an admission, availability of care, continued stay or health care service for which the covered person received emergency services, but has not been discharged from a facility. B. 1. Upon receipt of a request for an expedited external review, the Commissioner immediately shall send a copy of the request to the health carrier. 2. Immediately upon receipt of the request pursuant to paragraph (1), the health carrier shall determine whether the request meets the reviewability requirements set forth in Rule 15.07(B) of this Regulation. The health carrier shall immediately notify the Commissioner and the covered person and, if applicable, the covered person’s authorized representative of its eligibility determination. 3. a. The Commissioner may specify the form for the health carrier’s notice of initial determination under this subsection and any supporting information to be included in the notice. b. The notice of initial determination shall include a statement informing the covered person and, if applicable, the covered person’s authorized representative that a health carrier’s initial determination that an external review request is ineligible for review may be appealed to the Commissioner. 4. a. The Commissioner may determine that a request is eligible for external review under Rule 15.07(B) of this Regulation notwithstanding a health carrier’s initial determination that the request is ineligible and require that it be referred for external review. b. In making a determination under subparagraph (a) of this paragraph, the Commissioner’s decision shall be made in accordance with the terms of the covered person’s health benefit plan and shall be subject to all applicable provisions of this Regulation. 5. Upon receipt of the notice that the request meets the reviewability requirements, the Commissioner immediately shall assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations compiled and maintained by the Commissioner pursuant to Rule 15.11 of this Regulation. The Commissioner shall immediately notify the health carrier of the name of the assigned independent review organization. 6. In reaching a decision in accordance with subsection E, the assigned independent review organization is not bound by any decisions or conclusions reached during the health carrier’s utilization review process or the health carrier’s internal grievance process. C. Upon receipt of the notice from the Commissioner of the name of the independent review organization assigned to conduct the expedited external review pursuant to subsection B(5), the health carrier or its designee utilization review organization shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization electronically or by telephone or facsimile or any other available expeditious method. D. In addition to the documents and information provided or transmitted pursuant to subsection C, the assigned 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 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, covered person, the covered person’s authorized representative or the covered person’s treating provider; 4. The terms of coverage under the covered person’s health benefit plan with the health carrier to ensure that the independent review organization’s decision is not contrary to the terms of coverage under the covered person’s health benefit plan with the health carrier; 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 after considering paragraphs (1) through (6) to the extent the information and documents are available and the clinical reviewer or reviewers consider appropriate. E. 1. As expeditiously as the covered person’s medical condition or circumstances requires, but in no event more than seventy-two (72) hours after the date of receipt of the request for an expedited external review that meets the reviewability requirements set forth in Rule 15.07(B) of this Regulation, the assigned independent review organization shall: a. Make a decision to uphold or reverse the adverse determination or final adverse determination; and b. Notify the covered person, if applicable, the covered person’s authorized representative, the health carrier, and the Commissioner of the decision. 2. If the notice provided pursuant to paragraph (1) was not in writing, within forty-eight (48) hours after the date of providing that notice, the assigned independent review organization shall: a. Provide written confirmation of the decision to the covered person, if applicable, the covered person’s authorized representative, the health carrier, and the Commissioner; and b. Include the information set forth in Rule 15.07(I)(2) of this Regulation. 3. Upon receipt of the notice a decision pursuant to paragraph (1) reversing the adverse determination or final adverse determination, the health carrier immediately shall approve the coverage that was the subject of the adverse determination or final adverse determination. F. An expedited external review may not be provided for retrospective adverse or final adverse determinations. G. The assignment by the Commissioner of an approved independent review organization to conduct an external review in accordance with this section shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the health care service that is the subject of the adverse determination or final adverse determination and other circumstances, including conflict of interest concerns pursuant to Rule 15.12(D) of this Regulation.