Qualifications of persons reviewing appeals

Qualifications of persons reviewing appeals 1) A health insurance issuer must ensure that all appeals are reviewed by a physician when the request is by a physician or a representative of a physician. The physician must: a. Possess a current and valid nonrestricted license to practice medicine in any United States jurisdiction; b. Be certified by the board(s) of the American Board of Medical Specialists or the American Board of Osteopathy within the relevant specialty of a physician who typically manages the medical condition or disease; c. Be knowledgeable of, and have experience providing, the health care services under appeal; d. Not have been directly involved in making the adverse determination; and e. Consider all known clinical aspects of the health care service under review, including, but not limited to, a review of all pertinent medical records provided to the health insurance issuer by the enrollee's health care professional or health care provider and any medical literature provided to the health insurance issuer by the health care professional or health care provider.