<html> <head> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <title>Rule 20:06:53 EXTERNAL AND INTERNAL REVIEW</title> <META NAME="Keywords" Content="Administrative Rules 20:06:53"> <META NAME="Description" Content="Administrative Rules 20:06:53 EXTERNAL AND INTERNAL REVIEW"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p align=center><b>CHAPTER 20:06:53</b></p> <p align=center><b>&nbsp;</b></p> <p align=center><b>EXTERNAL AND INTERNAL REVIEW</b></p> <p><a href="DisplayRule.aspx?Rule=20:06:53:01">20:06:53:01</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Definitions.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:02">20:06:53:02</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Applicability.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:03">20:06:53:03</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Notice of right to external review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:04">20:06:53:04</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Content of notices.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:05">20:06:53:05</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Review procedures and authorization to accompany notice.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:06">20:06:53:06</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Request for external review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:07">20:06:53:07</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Exhaustion of internal grievance process required.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:08">20:06:53:08</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; When exhaustion of internal grievance occurs.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:09">20:06:53:09</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Request for expedited review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:10">20:06:53:10</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Determination of expedited review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:11">20:06:53:11</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Waiver of exhaustion requirement.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:12">20:06:53:12</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Standard external review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:13">20:06:53:13</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Notification following preliminary review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:14">20:06:53:14</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Determination by the director and assignment of independent review organization.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:15">20:06:53:15</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Independence of review decision.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:16">20:06:53:16</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Health carrier required to provide information.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:17">20:06:53:17</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Effect of failure to act on external review process.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:18">20:06:53:18</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Independent review organization review of information.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:19">20:06:53:19</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Carrier reconsideration.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:20">20:06:53:20</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Information to be considered by independent review organization.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:21">20:06:53:21</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Independent review organization decisions.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:22">20:06:53:22</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Director assignment of independent review organization.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:23">20:06:53:23</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Expedited external review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:24">20:06:53:24</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Notifications upon request for expedited external review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:25">20:06:53:25</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Director's determination of eligibility for expedited reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:26">20:06:53:26</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Director assignment of independent review organization for expedited reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:27">20:06:53:27</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Independent review organization decision for expedited reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:28">20:06:53:28</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Information to be considered by independent review organization for expedited review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:29">20:06:53:29</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Expedited review decision.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:30">20:06:53:30</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Health carrier required to approve upon reversal by expedited review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:31">20:06:53:31</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Assignment of independent review organization for expedited reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:32">20:06:53:32</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Applicability of expedited reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:33">20:06:53:33</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; External review of experimental or investigational treatment adverse determinations.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:34">20:06:53:34</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Notifications upon request for external review of experimental or investigational treatment adverse determinations.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:35">20:06:53:35</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Director's determination of eligibility and assignment for external review of experimental or investigational treatment.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:36">20:06:53:36</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Health carrier preliminary review of request for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:37">20:06:53:37</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Health carrier notification after preliminary review of request for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:38">20:06:53:38</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Director's determination of request for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:39">20:06:53:39</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Health carrier notification of eligibility for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:40">20:06:53:40</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Independent review organization experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:41">20:06:53:41</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Independent review organization clinical reviewer written opinion for experimental or investigational treatment reviews.</p> <p>20:06:43:42&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Records provided to independent review organization for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:43">20:06:53:43</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Review of information by independent review organization for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:44">20:06:53:44</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Reconsideration by health carrier for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:45">20:06:53:45</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Clinical review opinion for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:46">20:06:53:46</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Expedited review opinions for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:47">20:06:53:47</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Clinical review criteria for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:48">20:06:53:48</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Independent review organization decision and notice for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:49">20:06:53:49</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Expedited reviews upon receipt of clinical review opinion for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:50">20:06:53:50</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Decision by independent review organization for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:51">20:06:53:51</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Notice of written decision by independent review organization for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:52">20:06:53:52</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Health carrier requirement upon notice of decision reversing adverse determination for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:53">20:06:53:53</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Criteria for assignment of independent review organization for experimental or investigational treatment reviews.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:54">20:06:53:54</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Binding nature of external review decision.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:55">20:06:53:55</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Approval of independent review organizations.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:56">20:06:53:56</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Continuation of approval for independent review organizations.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:57">20:06:53:57</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Minimum qualifications for independent review organizations.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:58">20:06:53:58</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Requirements for clinical reviewers.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:59">20:06:53:59</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Subsidiaries of or ownership in independent review organizations.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:60">20:06:53:60</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Independence of clinical reviewers.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:61">20:06:53:61</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Nationally accredited independent review organizations.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:62">20:06:53:62</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Unbiased independent review organization.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:63">20:06:53:63</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Hold harmless for independent review organizations.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:64">20:06:53:64</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; External review reporting requirements.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:65">20:06:53:65</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Independent review organization and health carrier recordkeeping.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:66">20:06:53:66</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Funding of external review.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:67">20:06:53:67</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Disclosure requirements.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:68">20:06:53:68</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Adverse benefit determination -- Defined.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:69">20:06:53:69</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Urgent care requests -- Timely notification of determination -- Initial benefit determination.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:70">20:06:53:70</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Additional evidence.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:71">20:06:53:71</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Avoiding conflicts of interest.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:72">20:06:53:72</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Notice to enrollee.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:73">20:06:53:73</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Failure to comply with internal claims and appeal process.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:74">20:06:53:74</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Continued coverage and ongoing treatment.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:75">20:06:53:75</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; One level of internal appeals.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:76">20:06:53:76</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Record keeping.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:77">20:06:53:77</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Applicability.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:78">20:06:53:78</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Strictly adhere -- Defined.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:79">20:06:53:79</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Written explanation of violation.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:80">20:06:53:80</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Procedure when immediate review request denied.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:0A">Appendix A</a>&nbsp;&nbsp; Model notice of appeal rights.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:0B">Appendix B</a>&nbsp;&nbsp; Model external review request form.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:0C">Appendix C</a>&nbsp;&nbsp; Independent review organization external review annual report form.</p> <p><a href="DisplayRule.aspx?Rule=20:06:53:0D">Appendix D</a>&nbsp;&nbsp; Model health carrier external review annual report form.</p> </div> </body> </html>