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CHAPTER 20:06:53

 

EXTERNAL AND INTERNAL REVIEW

20:06:53:01        Definitions.

20:06:53:02        Applicability.

20:06:53:03        Notice of right to external review.

20:06:53:04        Content of notices.

20:06:53:05        Review procedures and authorization to accompany notice.

20:06:53:06        Request for external review.

20:06:53:07        Exhaustion of internal grievance process required.

20:06:53:08        When exhaustion of internal grievance occurs.

20:06:53:09        Request for expedited review.

20:06:53:10        Determination of expedited review.

20:06:53:11        Waiver of exhaustion requirement.

20:06:53:12        Standard external review.

20:06:53:13        Notification following preliminary review.

20:06:53:14        Determination by the director and assignment of independent review organization.

20:06:53:15        Independence of review decision.

20:06:53:16        Health carrier required to provide information.

20:06:53:17        Effect of failure to act on external review process.

20:06:53:18        Independent review organization review of information.

20:06:53:19        Carrier reconsideration.

20:06:53:20        Information to be considered by independent review organization.

20:06:53:21        Independent review organization decisions.

20:06:53:22        Director assignment of independent review organization.

20:06:53:23        Expedited external review.

20:06:53:24        Notifications upon request for expedited external review.

20:06:53:25        Director's determination of eligibility for expedited reviews.

20:06:53:26        Director assignment of independent review organization for expedited reviews.

20:06:53:27        Independent review organization decision for expedited reviews.

20:06:53:28        Information to be considered by independent review organization for expedited review.

20:06:53:29        Expedited review decision.

20:06:53:30        Health carrier required to approve upon reversal by expedited review.

20:06:53:31        Assignment of independent review organization for expedited reviews.

20:06:53:32        Applicability of expedited reviews.

20:06:53:33        External review of experimental or investigational treatment adverse determinations.

20:06:53:34        Notifications upon request for external review of experimental or investigational treatment adverse determinations.

20:06:53:35        Director's determination of eligibility and assignment for external review of experimental or investigational treatment.

20:06:53:36        Health carrier preliminary review of request for experimental or investigational treatment reviews.

20:06:53:37        Health carrier notification after preliminary review of request for experimental or investigational treatment reviews.

20:06:53:38        Director's determination of request for experimental or investigational treatment reviews.

20:06:53:39        Health carrier notification of eligibility for experimental or investigational treatment reviews.

20:06:53:40        Independent review organization experimental or investigational treatment reviews.

20:06:53:41        Independent review organization clinical reviewer written opinion for experimental or investigational treatment reviews.

20:06:43:42        Records provided to independent review organization for experimental or investigational treatment reviews.

20:06:53:43        Review of information by independent review organization for experimental or investigational treatment reviews.

20:06:53:44        Reconsideration by health carrier for experimental or investigational treatment reviews.

20:06:53:45        Clinical review opinion for experimental or investigational treatment reviews.

20:06:53:46        Expedited review opinions for experimental or investigational treatment reviews.

20:06:53:47        Clinical review criteria for experimental or investigational treatment reviews.

20:06:53:48        Independent review organization decision and notice for experimental or investigational treatment reviews.

20:06:53:49        Expedited reviews upon receipt of clinical review opinion for experimental or investigational treatment reviews.

20:06:53:50        Decision by independent review organization for experimental or investigational treatment reviews.

20:06:53:51        Notice of written decision by independent review organization for experimental or investigational treatment reviews.

20:06:53:52        Health carrier requirement upon notice of decision reversing adverse determination for experimental or investigational treatment reviews.

20:06:53:53        Criteria for assignment of independent review organization for experimental or investigational treatment reviews.

20:06:53:54        Binding nature of external review decision.

20:06:53:55        Approval of independent review organizations.

20:06:53:56        Continuation of approval for independent review organizations.

20:06:53:57        Minimum qualifications for independent review organizations.

20:06:53:58        Requirements for clinical reviewers.

20:06:53:59        Subsidiaries of or ownership in independent review organizations.

20:06:53:60        Independence of clinical reviewers.

20:06:53:61        Nationally accredited independent review organizations.

20:06:53:62        Unbiased independent review organization.

20:06:53:63        Hold harmless for independent review organizations.

20:06:53:64        External review reporting requirements.

20:06:53:65        Independent review organization and health carrier recordkeeping.

20:06:53:66        Funding of external review.

20:06:53:67        Disclosure requirements.

20:06:53:68        Adverse benefit determination -- Defined.

20:06:53:69        Urgent care requests -- Timely notification of determination -- Initial benefit determination.

20:06:53:70        Additional evidence.

20:06:53:71        Avoiding conflicts of interest.

20:06:53:72        Notice to enrollee.

20:06:53:73        Failure to comply with internal claims and appeal process.

20:06:53:74        Continued coverage and ongoing treatment.

20:06:53:75        One level of internal appeals.

20:06:53:76        Record keeping.

20:06:53:77        Applicability.

20:06:53:78        Strictly adhere -- Defined.

20:06:53:79        Written explanation of violation.

20:06:53:80        Procedure when immediate review request denied.

Appendix A   Model notice of appeal rights.

Appendix B   Model external review request form.

Appendix C   Independent review organization external review annual report form.

Appendix D   Model health carrier external review annual report form.


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