New Hampshire Revised Statutes 420-J:5-e – General Provisions Regarding External Review
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I. The health carrier against which a request for external review is filed shall pay the cost of the external review. Except under the circumstances described below in this paragraph, such costs shall not exceed $1,500. The commissioner shall notify the independent review organizations of the cost limitation for conducting an external review. The cost for an external review may exceed $1,500 if the commissioner determines an additional cost is necessary to ensure the fair adjudication of the case in question.
II. The external review decision of the independent review organization shall be binding on the health carrier and shall be enforceable by the commissioner pursuant to the penalty provisions of N.H. Rev. Stat. § 420-J:14. The external review decision of the independent review organization shall be binding on the covered person except to the extent the covered person has other remedies available under federal or state law. The external review process shall not be considered an adjudicative proceeding within the meaning of RSA 541-A, and the external review decision of the independent review organization shall not be subject to rehearing and appeal pursuant to RSA 541.
III. An independent review organization shall maintain all standards of confidentiality. The records and internal materials prepared for specific reviews by an independent review organization under this section shall be exempt from public disclosure under RSA 91-A.
IV. An external review organization acting in good faith shall have immunity from any civil or criminal liability or professional discipline as a result of acts or omissions with respect to any external review, unless the acts or omissions constitute willful and wanton misconduct.
V. The right to external review under this chapter shall not be construed to change the terms of coverage under a health benefit plan nor shall the health carrier retaliate against the covered person for exercising his or her right to an independent external review.
VI. When requested by the covered person, the commissioner shall provide consumer assistance in pursuing the internal grievance procedures under N.H. Rev. Stat. § 420-J:5 and the external review process under N.H. Rev. Stat. § 420-J:5-a-420-J:5-e.
VII. The commissioner shall report annually to the governor and the legislature on the number of grievances subjected to external review, the number of decisions resolved wholly or partially in favor of the covered person, and the number of decisions resolved wholly or partially in favor of the health carrier. Such reports shall also include a separate statement of the number of cases in which the external review was terminated as a result of a reversal by the health carrier of its adverse determination after the receipt of new or additional information from the covered person or the covered person’s authorized representative and the number of cases in which the covered person and the health carrier agreed to resolve the dispute prior to a final determination by the independent review organization.
VIII. If, based on the evidence presented during the external review process, the commissioner determines that the health carrier’s medical director, in the conduct of his or her duties, may have committed misconduct as set forth in N.H. Rev. Stat. § 329:17, VI, the commissioner shall document such findings and transmit them in a separate report to the board of medicine.
II. The external review decision of the independent review organization shall be binding on the health carrier and shall be enforceable by the commissioner pursuant to the penalty provisions of N.H. Rev. Stat. § 420-J:14. The external review decision of the independent review organization shall be binding on the covered person except to the extent the covered person has other remedies available under federal or state law. The external review process shall not be considered an adjudicative proceeding within the meaning of RSA 541-A, and the external review decision of the independent review organization shall not be subject to rehearing and appeal pursuant to RSA 541.
Terms Used In New Hampshire Revised Statutes 420-J:5-e
- 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.
- 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.
- person: may extend and be applied to bodies corporate and politic as well as to individuals. See New Hampshire Revised Statutes 21:9
- state: when applied to different parts of the United States, may extend to and include the District of Columbia and the several territories, so called; and the words "United States" shall include said district and territories. See New Hampshire Revised Statutes 21:4
III. An independent review organization shall maintain all standards of confidentiality. The records and internal materials prepared for specific reviews by an independent review organization under this section shall be exempt from public disclosure under RSA 91-A.
IV. An external review organization acting in good faith shall have immunity from any civil or criminal liability or professional discipline as a result of acts or omissions with respect to any external review, unless the acts or omissions constitute willful and wanton misconduct.
V. The right to external review under this chapter shall not be construed to change the terms of coverage under a health benefit plan nor shall the health carrier retaliate against the covered person for exercising his or her right to an independent external review.
VI. When requested by the covered person, the commissioner shall provide consumer assistance in pursuing the internal grievance procedures under N.H. Rev. Stat. § 420-J:5 and the external review process under N.H. Rev. Stat. § 420-J:5-a-420-J:5-e.
VII. The commissioner shall report annually to the governor and the legislature on the number of grievances subjected to external review, the number of decisions resolved wholly or partially in favor of the covered person, and the number of decisions resolved wholly or partially in favor of the health carrier. Such reports shall also include a separate statement of the number of cases in which the external review was terminated as a result of a reversal by the health carrier of its adverse determination after the receipt of new or additional information from the covered person or the covered person’s authorized representative and the number of cases in which the covered person and the health carrier agreed to resolve the dispute prior to a final determination by the independent review organization.
VIII. If, based on the evidence presented during the external review process, the commissioner determines that the health carrier’s medical director, in the conduct of his or her duties, may have committed misconduct as set forth in N.H. Rev. Stat. § 329:17, VI, the commissioner shall document such findings and transmit them in a separate report to the board of medicine.