Louisiana Revised Statutes 22:2433 – Notice of right to external review
Terms Used In Louisiana Revised Statutes 22:2433
- Adverse determination: means any of the following:
(a) A determination by a health insurance issuer or its designee utilization review organization that, based upon the information provided, a request for a benefit under the health insurance issuer's health benefit plan upon application of any utilization review technique does not meet the health insurance issuer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced, or terminated or payment is not provided or made, in whole or in part, for the benefit. See Louisiana Revised Statutes 22:2392
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Authorized representative: means any of the following:
(a) A person to whom a covered person has given express written consent to represent the covered person for purposes of this Chapter. See Louisiana Revised Statutes 22:2392
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:2392
- Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Louisiana Revised Statutes 22:2392
- Disclose: means to release, transfer, or otherwise divulge protected health information to any person other than the individual who is the subject of the protected health information. See Louisiana Revised Statutes 22:2392
- Emergency services: means health care items and services furnished or required to evaluate and treat an emergency medical condition. See Louisiana Revised Statutes 22:2392
- Facility: means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, rehabilitation and other therapeutic health settings, and inpatient hospice facilities. See Louisiana Revised Statutes 22:2392
- Final adverse determination: means an adverse determination, including medical judgment, involving a covered benefit that has been upheld by a health insurance issuer, or its designee utilization review organization, at the completion of the health insurance issuer's internal claims and appeals process procedures provided pursuant to La. See Louisiana Revised Statutes 22:2392
- Grievance: means , in a health insurance issuer's internal claims and appeals process, a written complaint or oral complaint, if the complaint involves an urgent care request submitted by or on behalf of a covered person regarding any of the following:
(a) Availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review. See Louisiana Revised Statutes 22:2392
- Health information: means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to any of the following:
(a) The past, present, or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family. See Louisiana Revised Statutes 22:2392
- Health insurance issuer: means an entity subject to the insurance laws and regulations 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 through a health benefit plan as defined in this Section, and shall include a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits. See Louisiana Revised Statutes 22:2392
- Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Louisiana Revised Statutes 22:2392
- person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
- Protected health information: means either of the following:
(a) Health information that identifies an individual who is the subject of the information. See Louisiana Revised Statutes 22:2392
- provider: means a health care professional or a facility. See Louisiana Revised Statutes 22:2392
A.(1) For matters involving an issue of medical necessity, appropriateness, health care setting, level of care, effectiveness, or a rescission, a health insurance issuer shall notify the covered person in writing of the covered person‘s right to request an external review to be conducted pursuant to La. Rev. Stat. 22:2436 through 2438 and include the appropriate statements and information set forth in Subsection B of this Section at the same time that the health insurance issuer sends written notice of:
(a) An adverse determination upon completion of the health insurance issuer’s internal claims and appeals process provided pursuant to La. Rev. Stat. 22:2401.
(b) A final adverse determination.
(2) As part of the written notice required pursuant to Paragraph (1) of this Subsection, a health insurance issuer shall include the following, or substantially equivalent, language: “We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us. In order to request an external appeal, you should send your request in writing to our office at the designated address included in this notice.”
(3) The commissioner may prescribe by regulation the form and content of the notice required pursuant to this Section.
B.(1) The health insurance issuer shall include in the notice required pursuant to Subsection A of this Section:
(a) For a notice related to an adverse determination, a statement informing the covered person that:
(i) If the covered person has a medical condition for which the time frame for completion of an expedited review of a grievance involving an adverse determination as provided pursuant to La. Rev. Stat. 22:2401 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or his authorized representative may file a request for an expedited external review to be conducted pursuant to La. Rev. Stat. 22:2437. Further, the notice shall inform the covered person that an expedited external review pursuant to La. Rev. Stat. 22:2438 is available if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating physician certifies in writing that any delay in appealing the adverse determination may pose an imminent threat to the covered person’s health, including but not limited to severe pain, potential loss of life, limb, or major bodily function, or the immediate deterioration of the health of the covered person. The notice shall also inform the covered person or his authorized representative that he may simultaneously file a request for an expedited review of a grievance involving an adverse determination as provided pursuant to La. Rev. Stat. 22:2401, but that the independent review organization assigned to conduct the expedited external review will determine whether the covered person shall be required to complete the expedited review of the grievance prior to conducting the expedited external review.
(ii) The covered person or his authorized representative may file a grievance under the health insurance issuer’s internal claims and appeals process as provided pursuant to La. Rev. Stat. 22:2401, but if the health insurance issuer has not issued a written decision to the covered person or his authorized representative within thirty days following the date the covered person or his authorized representative files the grievance with the health insurance issuer and the covered person or his authorized representative has not requested or agreed to a delay, the covered person or his authorized representative may file a request for external review pursuant to La. Rev. Stat. 22:2434 and shall be considered to have exhausted the health insurance issuer’s internal claims and appeals process for purposes of La. Rev. Stat. 22:2435.
(b) For a notice related to a final adverse determination, a statement informing the covered person that:
(i) If the covered person has a medical condition for which the time frame for completion of a standard external review pursuant to La. Rev. Stat. 22:2436 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or his authorized representative may file a request for an expedited external review pursuant to La. Rev. Stat. 22:2437.
(ii) If the final adverse determination concerns either of the following:
(aa) An admission, availability of care, continued stay, or health care service for which the covered person received emergency services, but has not been discharged from a facility, the covered person or his authorized representative may request an expedited external review pursuant to La. Rev. Stat. 22:2437.
(bb) A denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational, the covered person or his authorized representative may file a request for a standard external review to be conducted pursuant to La. Rev. Stat. 22:2438 or if the covered person’s treating physician certifies in writing that any delay in appealing the adverse determination may pose an imminent threat to the covered person’s health, including but not limited to severe pain, potential loss of life, limb, or major bodily function, or the immediate deterioration of the health of the covered person, the covered person or his authorized representative may request an expedited external review to be conducted under La. Rev. Stat. 22:2438.
(2) In addition to the information to be provided pursuant to Paragraph (1) of this Subsection, the health insurance issuer shall include a copy of the description of both the standard and expedited external review procedures the health insurance issuer is required to provide pursuant to La. Rev. Stat. 22:2445, highlighting the provisions in the external review procedures that give the covered person or his authorized representative the opportunity to submit additional information and including any forms used to process an external review.
(3) As part of any forms provided under Paragraph (2) of this Subsection, the health insurance issuer shall include an authorization form, or other document approved by the commissioner that complies with the requirements of 45 C.F.R. § 164.508, by which the covered person, for purposes of conducting an external review under this Part, authorizes the health insurance issuer and the covered person’s treating health care provider to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review, as further provided in this Paragraph. A health insurance issuer shall not use or disclose protected health information for any purpose other than in the performance of the health insurance issuer’s functions, except as otherwise permitted by state or federal law, including providing such information to an independent review organization as required by this Part.
Acts 2013, No. 326, §1, eff. Jan. 1, 2015.