(a) Except as provided in subsection (f), an aggrieved person may make a request for an expedited external review with the health carrier at the time the aggrieved person receives:
(1) An adverse determination if:
(A) The adverse determination involves a medical condition of the covered person for which the timeframe for completion of an expedited internal review of a grievance involving an adverse determination set forth in § 56-61-109 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function; and(B) The aggrieved person has filed a request for an expedited review of a grievance involving an adverse determination as set forth in § 56-61-109; or(2) A final adverse determination:
(A) If the covered person has a medical condition where the timeframe for completion of a standard external review pursuant to § 56-61-116 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function; or(B) If the final adverse determination concerns an admission, availability of care, continued stay or healthcare service for which the covered person received emergency services, but has not been discharged from a facility.(b)(1) Immediately upon receipt of the request, the health carrier shall determine whether the request meets the reviewability requirements set forth in § 56-61-116. The health carrier shall immediately notify the aggrieved person of its eligibility determination regarding the availability of external review.(2) The notice of initial determination shall include a statement informing the aggrieved person that a health carrier’s initial determination that an external review request is ineligible for review and that the aggrieved person may file a complaint with the commissioner.
(A) The commissioner may determine that a request is eligible for external review notwithstanding a health carrier’s initial determination that the request is ineligible and that it be referred to external review.(B) In making a determination under subdivision (b)(2)(A), the commissioner’s decision shall be made in accordance with the terms of the covered person’s health benefit plan and shall be subject to all applicable provisions of this chapter.(c) Upon making a determination that a request is eligible for expedited external review, the health carrier shall immediately notify the aggrieved person in writing that the request is eligible for external review.(d) At the same time, the health carrier shall immediately notify the external review organization and provide or transmit all necessary documents and information considered when making the adverse determination or final adverse determination electronically or by telephone, facsimile or any other expeditious method available.(e) In addition to the documents and information provided or transmitted pursuant to subsection (d), the external review organization, to the extent that the information or documents are available and the external review organization considers them appropriate, shall consider the following in reaching a decision:
(1) The covered person’s pertinent medical records;(2) The attending healthcare professional‘s recommendation;(3) Consulting reports from appropriate healthcare professionals and other documents submitted by the health carrier or the aggrieved person;(4) The terms of coverage under the covered person’s health benefit plan with the health carrier to ensure that the external review organization’s decision is not contrary to the terms of coverage under the covered person’s health benefit plan with the health carrier;(5) The most appropriate practice guidelines, which shall include medical or scientific evidence based standards;(6) Applicable clinical review criteria developed and used by the health carrier in making adverse determinations;(7) Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including:
(A) The federal agency for healthcare research and quality;(B) The national institutes of health;(C) The national cancer institute;(D) The national academy of sciences;(E) The centers for medicare & medicaid services;(F) The federal food and drug administration; and(G) Any national board recognized by the national institutes of health for the purpose of evaluating the medical value of healthcare services; and(8) The opinion of the external review organization’s clinical reviewer or reviewers after considering subdivisions (e)(1)-(7) to the extent that the information and documents are available and the clinical reviewer or reviewers consider appropriate.(f)(1)(A) As expeditiously as the covered person’s medical condition or circumstances requires, but in no event more than seventy-two (72) hours after the date of receipt of the request for an expedited external review that meets the reviewability requirements, the external review organization shall make a decision to uphold or reverse the adverse determination or final adverse determination; and(B) Notify the health carrier of the decision and the health carrier must immediately notify the aggrieved person of the external review organization’s decision. The aggrieved person must receive the decision of the expedited external review within seventy-two (72) hours after the date of receipt of the request for expedited external review.(2)(A) If the notice provided pursuant to subdivision (f)(1) was not in writing, within forty-eight (48) hours after the date of providing such notice, the external review organization shall provide written confirmation of the decision to the health carrier; and include the information set forth in this section.(B) The health carrier shall immediately notify the aggrieved person of the external review organization’s decision and include the information set forth in this section.(C) Upon receipt of notice of the decision rendered pursuant to subdivision (f)(1) reversing the adverse determination or final adverse determination, the health carrier shall immediately approve the coverage that was the subject of the adverse determination or the final adverse determination.(g) An expedited external review shall not be provided for retrospective adverse determinations or final adverse determinations.
