58-17I-7 Review of adverse determination--Time for filing--Designation and notice of reviewers--Sco...
Review of adverse determination--Time for filing--Designation and notice of
reviewers--Scope of review.
Within one hundred eighty days after the date of receipt of a notice of
an adverse determination sent pursuant to chapter 58-17H, any covered person or the covered
person's authorized representative may file a grievance with the health carrier requesting a first level
review of the adverse determination. The health carrier shall provide the covered person with the
name, address, and telephone number of a person or organizational unit designated to coordinate the
first level review on behalf of the health carrier. In providing for a first level review under this
section, the health carrier shall ensure that the review conducted in a manner under this section to
ensure the independence and impartiality of the individuals involved in making the first level review
decision. In ensuring the independence and impartiality of individuals involved in making the first
level review decision, no health carrier may make decisions related to such individuals regarding
hiring, compensation, termination, promotion or other similar matters based upon the likelihood that
the individual will support the denial of benefits.
The health carrier shall designate one or more health care providers who have appropriate
training and experience in the field of medicine involved in the medical judgment to evaluate the
adverse determination. No health care provider may have been involved in the initial adverse
determination. In conducting the review, a reviewer shall take into consideration all comments,
documents, records, and other information regarding the request for services submitted by the
covered person or the covered person's authorized representative, without regard to whether the
information was submitted or considered in making the initial adverse determination. (SL 2012, ch
239, § 1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed
repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119
(2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a
federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.")
Source: SL 2011, ch 219, § 79.