(a) An external review decision shall be binding on the health carrier and the enrollee except to the extent that the health carrier or the enrollee has other remedies available under applicable federal or state law.

Terms Used In Hawaii Revised Statutes 432E-37

  • Adverse action: means an adverse determination or a final adverse determination. 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

  • 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
  • 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
  • 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
(b) An enrollee or the enrollee’s appointed representative shall not file a subsequent request for external review involving the same adverse action for which the enrollee has already received an external review decision pursuant to this part.

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