(a) An enrollee or the enrollee’s appointed representative may file a request for an external review with the commissioner within one hundred thirty days of receipt of notice of an adverse action. Within three business days after the receipt of a request for external review pursuant to this section, the commissioner shall send a copy of the request to the health carrier.
Terms Used In Hawaii Revised Statutes 432E-34
- Adverse action: means an adverse determination or a final adverse determination. See Hawaii Revised Statutes 432E-1
- Adverse determination: means a determination by a health carrier or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. See Hawaii Revised Statutes 432E-1
- Appointed representative: means a person who is expressly permitted by the enrollee or who has the power under Hawaii law to make health care decisions on behalf of the enrollee, including:
(1) A person to whom an enrollee has given express written consent to represent the enrollee in an external review;
(2) A person authorized by law to provide substituted consent for an enrollee;
(3) A family member of the enrollee or the enrollee's treating health care professional, only when the enrollee is unable to provide consent;
(4) A court-appointed legal guardian;
(5) A person who has a durable power of attorney for health care; or
(6) A person who is designated in a written advance directive;
provided that an appointed representative shall include an "authorized representative" as used in the federal Patient Protection and Affordable Care Act. See Hawaii Revised Statutes 432E-1
- Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services. See Hawaii Revised Statutes 432E-1
- Commissioner: means the insurance commissioner. See Hawaii Revised Statutes 432E-1
- Enrollee: means a person who enters into a contractual relationship under or who is provided with health care services or benefits through a health benefit plan. See Hawaii Revised Statutes 432E-1
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- External review: means a review of an adverse determination (including a final adverse determination) conducted by an independent review organization pursuant to this chapter. See Hawaii Revised Statutes 432E-1
- Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health carrier or its designated utilization review organization at the completion of the health carrier's internal grievance process procedures, or an adverse determination with respect to which the internal appeals process is deemed to have been exhausted under section 432E-33(b). See Hawaii Revised Statutes 432E-1
- Health benefit plan: means a policy, contract, certificate or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay or reimburse any of the costs of health care services. See Hawaii Revised Statutes 432E-1
- Health care professional: means an individual licensed, accredited, or certified to provide or perform specified health care services in the ordinary course of business or practice of a profession consistent with state law. See Hawaii Revised Statutes 432E-1
- Health carrier: means an entity subject to the insurance laws and rules of this State, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a mutual benefit society, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits or health care services. See Hawaii Revised Statutes 432E-1
- Independent review organization: means an independent entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Hawaii Revised Statutes 432E-1
- Internal review: means the review under § 432E-5 of an enrollee's complaint by a health carrier. See Hawaii Revised Statutes 432E-1
- Medical necessity: means a health intervention that meets the criteria enumerated in section 432E-1. See Hawaii Revised Statutes 432E-1
- provider: means a health care professional. See Hawaii Revised Statutes 432E-1
- Retrospective review: means a review of medical necessity conducted after services that have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment. See Hawaii Revised Statutes 432E-1
- Reviewer: means an independent reviewer with clinical expertise either employed by or contracted by an independent review organization to perform external reviews. See Hawaii Revised Statutes 432E-1
- Uphold: The decision of an appellate court not to reverse a lower court decision.
- Utilization review: means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. See Hawaii Revised Statutes 432E-1
- Utilization review organization: means an entity that conducts utilization review other than a health carrier performing a review for its own health benefit plans. See Hawaii Revised Statutes 432E-1
If the request for external review submitted pursuant to this section is not complete, the health carrier shall inform the commissioner, the enrollee, and the enrollee’s appointed representative in writing that the request is incomplete and shall specify the information or materials required to complete the request.
If the enrollee is not eligible for external review pursuant to subsection (b), the health carrier shall inform the commissioner, the enrollee, and the enrollee’s appointed representative in writing that the enrollee is not eligible for external review and the reasons for ineligibility.
Notice of ineligibility for external review pursuant to this section shall include a statement informing the enrollee and the enrollee’s appointed representative that a health carrier’s initial determination that the external review request is ineligible for review may be appealed to the commissioner by submission of a request to the commissioner.
(d) Upon receipt of a request for appeal pursuant to subsection (c), the commissioner shall review the request for external review submitted by the enrollee pursuant to subsection (a), determine whether an enrollee is eligible for external review and, if eligible, shall refer the enrollee to external review. The commissioner’s determination of eligibility for external review shall be made in accordance with the terms of the enrollee’s health benefit plan and all applicable provisions of this part. If an enrollee is not eligible for external review, the commissioner shall notify the enrollee, the enrollee’s appointed representative, and the health carrier within three business days of the reason for ineligibility.
(e) When the commissioner receives notice pursuant to subsection (c) or makes a determination pursuant to subsection (d) that an enrollee is eligible for external review, within three business days after receipt of the notice or determination of eligibility, the commissioner shall:
(1) Randomly assign an independent review organization from the list of approved independent review organizations qualified to conduct the external review, based on the nature of the health care service that is the subject of the adverse action and other factors determined by the commissioner including conflicts of interest pursuant to § 432E-43, compiled and maintained by the commissioner to conduct the external review and notify the health carrier of the name of the assigned independent review organization; and
(2) Notify the enrollee and the enrollee’s appointed representative, in writing, of the enrollee’s eligibility and acceptance for external review.
(f) An enrollee or an enrollee’s appointed representative may submit additional information in writing to the assigned independent review organization for consideration in its external review. The independent review organization shall consider information submitted within five business days following the date of the enrollee’s receipt of the notice provided pursuant to subsection (e). The independent review organization may accept and consider additional information submitted by an enrollee or an enrollee’s appointed representative after five business days.
(g) Within five business days after the date of receipt of notice pursuant to subsection (e), the health carrier or its designated utilization review organization shall provide to the assigned independent review organization all documents and information it considered in issuing the adverse action that is the subject of external review. Failure by the health carrier or its utilization review organization to provide the documents and information within five business days shall not delay the conduct of the external review; provided that the assigned independent review organization may terminate the external review and reverse the adverse action that is the subject of the external review. The independent review organization shall notify the enrollee, the enrollee’s appointed representative, the health carrier, and the commissioner within three business days of the termination of an external review and reversal of an adverse action pursuant to this subsection.
(h) The assigned independent review organization shall, within one business day of receipt by the independent review organization, forward all information received from the enrollee pursuant to subsection (f) to the health carrier. Upon receipt of information forwarded to it pursuant to this subsection, a health carrier may reconsider the adverse action that is the subject of the external review; provided that reconsideration by the health carrier shall not delay or terminate an external review unless the health carrier reverses its adverse action and provides coverage or payment for the health care service that is the subject of the adverse action. The health carrier shall notify the enrollee, the enrollee’s appointed representative, the assigned independent review organization, and the commissioner in writing of its decision to reverse its adverse action within three business days of making its decision to reverse the adverse action and provide coverage. The assigned independent review organization shall terminate its external review upon receipt of notice pursuant to this subsection from the health carrier.
(i) In addition to the documents and information provided pursuant to subsections (f) and (g), the assigned independent review organization shall consider the following in reaching a decision:
(1) The enrollee’s medical records;
(2) The attending health care professional‘s recommendation;
(3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, enrollee, enrollee’s appointed representatives, or enrollee’s treating provider;
(4) The application of medical necessity as defined in § 432E-1;
(5) The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any practice guidelines developed by the federal government or national or professional medical societies, boards, and associations;
(6) Any applicable clinical review criteria developed and used by the health carrier or its designated utilization review organization; and
(7) The opinion of the independent review organization’s clinical reviewer or reviewers pertaining to the information enumerated in paragraphs (1) through (5) to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.
In reaching a decision, the assigned independent review organization shall not be bound by any decisions or conclusions reached during the health carrier’s utilization review or internal appeals process; provided that the independent review organization’s decision shall not contradict the terms of the enrollee’s health benefit plan or this part.
(j) Within forty-five days after it receives a request for an external review pursuant to subsection (e), the assigned independent review organization shall notify the enrollee, the enrollee’s appointed representative, the health carrier, and the commissioner of its decision to uphold or reverse the adverse action that is the subject of the internal review. The independent review organization shall include in the notice of its decision:
(1) A general description of the reason for the request for external review;
(2) The date the independent review organization received the assignment from the commissioner to conduct the external review;
(3) The date the external review was conducted;
(4) The date the decision was issued; and
(5) The basis for the independent review organization’s decision, including its reasoning, rationale, and the supporting evidence or documentation, including evidence-based standards, that the independent review organization considered in reaching its decision.
Upon receipt of a notice of a decision reversing the adverse action, the health carrier shall immediately approve the coverage that was the subject of the adverse action.
