(a) Except as provided in subsection (b), a request for an external review pursuant to § 56-61-116 or § 56-61-118 shall not be made until the aggrieved person has exhausted the health carrier‘s internal grievance process as set forth in this chapter.
(1) An aggrieved person shall be considered to have exhausted the health carrier’s internal grievance process for purposes of this section, if the aggrieved person:
(A) Has filed a grievance involving an adverse determination pursuant to § 56-61-107; and(B) Has not received a written decision on the grievance from the health carrier within thirty (30) days for prospective review determinations and sixty (60) days for retrospective review determinations following the date that the aggrieved person filed the grievance with the health carrier unless the aggrieved person requested or agreed to a delay.(2) Notwithstanding subdivision (a)(1)(B), an aggrieved person may not file a request for an external review of an adverse determination involving a retrospective review determination until the covered person has exhausted the health carrier’s internal grievance process.(b) A request for an external review of an adverse determination may be filed before the covered person has exhausted the health carrier’s internal grievance procedures, as set forth in § 56-61-107, whenever the health carrier agrees to waive the exhaustion requirement.(c) If the requirement to exhaust the health carrier’s internal grievance procedures is waived pursuant to subsection (b), the aggrieved person may file a request in writing for a standard external review as set forth in § 56-61-116 or § 56-61-118.
