(a) An independent review organization assigned pursuant to this part to conduct an external review shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it conducted an external review during a calendar year and upon request shall submit a report to the commissioner, as required under subsection (b).

Terms Used In Hawaii Revised Statutes 432E-41

  • 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

  • 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
  • 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 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 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
(b) Each independent review organization required to maintain written records on all requests for external review pursuant to subsection (a) for which it was assigned to conduct an external review shall submit to the commissioner, upon request, a report in the format specified by the commissioner. The report shall include in the aggregate by state, and for each health carrier:

(1) The total number of requests for external review;
(2) The number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse action and the number resolved reversing the adverse action;
(3) The average length of time for resolution;
(4) The summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the commissioner;
(5) The number of external reviews that were terminated as the result of a reconsideration by the health carrier of its adverse action after the receipt of additional information from the enrollee or the enrollee’s appointed representative; and
(6) Any other information the commissioner may request or require.

The independent review organization shall retain the written records required pursuant to this subsection for at least three years.

(c) Each health carrier shall maintain written records in the aggregate, by state and for each type of health benefit plan offered by the health carrier on all requests for external review that the health carrier receives notice of from the commissioner pursuant to this part.

Each health carrier required to maintain written records on all requests for external review shall submit to the commissioner, upon request, a report in the format specified by the commissioner that includes in the aggregate, by state, and by type of health benefit plan:

(1) The total number of requests for external review;
(2) From the total number of requests for external review reported, the number of requests determined eligible for a full external review; and
(3) Any other information the commissioner may request or require.

The health carrier shall retain the written records required pursuant to this subsection for at least three years.

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