3 AAC 28.938 - Expedited reviews of grievances involving an adverse determination
(a) A health care
insurer shall establish written procedures for the expedited review of an
urgent care request of a grievance involving an adverse determination. The
procedures must allow a covered person or the covered person's authorized
representative to request an expedited review under this section orally or in
writing.
(b) In addition to (a) of
this section, a health care insurer shall provide expedited review of a
grievance involving an adverse determination with respect to a concurrent
review urgent care request involving
(1) an
admission;
(2) availability of
care;
(3) a continued stay;
or
(4) a health care service for a
covered person who has received emergency services but has not been discharged
from a facility.
(c) A
health care insurer shall appoint an appropriate clinical peer or peers, in the
same or similar specialty as would typically manage the case being reviewed, to
review the adverse determination. A health care insurer may not designate a
person involved in making the initial adverse determination to be a clinical
peer.
(d) In an expedited review, a
health care insurer shall transmit all necessary information, including the
health care insurer's decision, to a covered person or the covered person's
authorized representative by telephone, facsimile transmission, electronic
mail, or the most expeditious method available.
(e) A health care insurer shall make an
expedited review decision and shall notify a covered person or the covered
person's authorized representative of the decision tinder (h) of this section
as expeditiously as the covered person's medical condition requires, but not
later than 72 hours after the receipt of the request for the expedited
review.
(f) If an expedited review
is of a grievance involving an adverse determination with respect to a
concurrent review urgent care request, a health care insurer shall continue
coverage of the services without liability to a covered person until the
covered person or the covered person's authorized representative is notified of
the determination.
(g) The time
period within which a decision is required to be made under (e) of this section
begins on the date a request is filed with a health care insurer under the
health care insurer's procedures established under
3
AAC 28.934 for filing a request, without regard to
whether all of the information necessary to make the determination accompanies
the filing.
(h) Except for
3
AAC 28.936(o)(7), the requirements
under 3 AAC 28.936(o) -
(q), for the review of a grievance involving an adverse determination, apply to
an expedited review of a grievance involving an adverse determination. An
expedited review of a grievance involving an adverse determination notice must
include a description of additional material or information necessary for a
covered person or the covered person's authorized representative to complete a
request, including an explanation of why the material or information is
necessary to complete the request.
Notes
Authority:AS 21.06.090
AS 21.07.005
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