3 AAC 28.958 - Standard external review

(a) A covered person or a covered person's authorized representative may file a request with the director for a standard external review of a health care insurer's adverse determination or final adverse determination not later than 180 days after

(1) receipt of a notice of an adverse determination or a final adverse determination;

(2) failure of a health care insurer to issue a written decision not later than 30 days after the covered person or the covered person's authorized representative filed a grievance involving an adverse determination under 3 AAC 28.956(b); or

(3) agreement of the health care insurer to waive the requirement that the covered person or the covered person's authorized representative exhaust the health care insurer's internal grievance procedures before filing a request for external review of an adverse determination under 3 AAC 28.956(f).

(b) The director will extend the ISO-day time period for filing the request if the

(1) covered person or the covered person's authorized representative files a request with the director seeking an extension; and

(2) the request for the extension sets out one or more justifications for the extension that a prudent person would consider to be a fair and reasonable basis for allowing the extension; the covered person or the covered person's authorized representative does not need to file the request for an extension under this subsection within the ISO-day filing period.

(c) Not later than one working day after receipt of a request for external review under (a) of this section, the director shall send written notice of the request to the health care insurer.

(d) Not later than five working days after receipt of the external review request under (c) of this section, the health care insurer shall complete a preliminary review of the request to determine whether

(1) the individual is or was a covered person under the health care insurance policy when the health care service or treatment was recommended or requested or, if the request concerns a retrospective review, was a covered person under the health care insurance policy when the health care service or treatment was provided;

(2) the health care service or treatment that is the subject of the adverse determination or final adverse determination is a covered service under the covered person's health care insurance policy but for a determination by the health care insurer that the health care service or treatment is not covered because the service or treatment does not meet the health care insurer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness;

(3) the covered person or the covered person's authorized representative has exhausted the health care insurer's internal grievance process, unless the covered person or the covered person's authorized representative is not required to exhaust the health care insurer's internal grievance process under 3 AAC 28.956 or this section; and

(4) the covered person or the covered person's authorized representative has provided all of the information and forms required to process an external review request, including the release form under 3 AAC 28.952(f).

(e) Not later than one working day after completion of a preliminary review under (d) of this section, a health care insurer shall notify in writing the covered person or the covered person's authorized representative, and also shall notify in writing the director, whether the request is

(1) complete; and

(2) eligible for external review.

(f) if a health care insurer determines the request is not complete, the health care insurer shall notify in writing the covered person or the covered person's authorized representative, and also shall notify in writing the director,

(1) that the request is not complete; and

(2) what information or materials are needed to make the request complete.

(g) If a health care insurer determines that a request is not eligible for external review, the health care insurer shall issue a notice of initial determination in writing informing the covered person or the covered person's authorized representative, and also informing the director, of that determination and the reasons why the request is not eligible for external review. The notice must include a statement that the covered person or the covered person's authorized representative may appeal the health care insurer's initial determination of ineligibility to the director.

(h) Notwithstanding a health care insurer's initial determination that a request is not eligible, the director may determine the request is eligible for external review under (d) of this section and refer the request for external review, The director will make the determination

(1) under the terms of the covered person's health care insurance policy; and

(2) subject to all applicable provisions under 3 AAC 28.950 - 3 AAC 28.982.

(i) Not later than one working day after receipt of notice of initial determination from a health care insurer that a request for external review is eligible for external review or upon a determination by the director that a request is eligible for external review, the director will

(1) assign an independent review organization to conduct the external review from the list of approved independent review organizations maintained under 3 AAC 28.970(c); the director will assign an independent review organization by rotation among those approved independent review organizations qualified to conduct the particular external review based on the nature of the health care service or treatment that is the subject of the adverse determination or final adverse determination and other circumstances, including conflict-of-interest concerns;

(2) notify the health care insurer of the name of the assigned independent review organization; and

(3) notify the covered person or the covered person's authorized representative in writing

(A) that the request is eligible;

(B) that the request is accepted for external review;

(C) of the name of the assigned independent review organization; and

(D) that the covered person or the covered person's authorized representative may submit in writing to the assigned independent review organization, not later than five working days after receipt of the notice, additional information that the independent review organization shall consider when conducting the external review; the independent review organization may accept and consider additional information submitted by the covered person or the covered person's authorized representative later than five working days after receipt of the notice.

(j) Not later than five working days after receipt of a notice of an assignment of an independent review organization, a health care insurer or the health care insurer's designee utilization review organization shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization. Except under (k) of this section, failure by a health care insurer or the health care insurer's designee utilization review organization to provide the documents and information during the time specified may not delay the conduct of the external review,

(k) If a health care insurer or health care insurer's designee utilization review organization fails to provide the documents and information during the time specified under (j) of this section, an assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination, Immediately after making a decision, the independent review organization shall notify the covered person or the covered person's authorized representative, and also shall notify the health care insurer and the director, of its decision.

(l) An assigned independent review organization shall review the information and documents received under (i)(3)(D) and (j) of this section. The assigned independent review organization shall forward the information and documents to the health care insurer not later than one working day after receipt of the information and documents submitted by the covered person or the covered person's authorized representative,

(m) Upon receipt of the information and documents forwarded to a health care insurer under (/) of this section, the health care insurer may reconsider the adverse determination or final adverse determination that is the subject of the external review. The health care insurer's reconsideration of its adverse determination or final adverse determination may not delay or terminate the external review. The external review shall only be terminated if the health care insurer decides, upon completion of the reconsideration, to reverse the health care insurer's determination and provide coverage or payment for the recommended or requested health care service or treatment that is the subject of the adverse determination or final adverse determination.

(n) Immediately after making a decision to reverse the health care insurer's adverse determination or final adverse determination, a health care insurer shall notify in writing the covered person or the covered person's authorized representative, and also shall notify in writing the assigned independent review organization and the director, of the health care insurer's decision. The assigned independent review organization shall terminate the external review upon receipt of notice of the health care insurer's decision to reverse the health care insurer's adverse determination or final adverse determination.

(o) In addition to the documents and information provided to an assigned independent review organization under (j) of this section, the independent review organization shall, to the extent the information or documents are available and the independent review organization considers them appropriate, consider the following in reaching a decision:

(1) the covered person's pertinent medical records;

(2) the attending physician or health care professional's recommendation or request;

(3) consulting reports from appropriate health care professionals and other documents submitted by the health care insurer, the covered person, the covered person's authorized representative, or the covered person's treating physician or other health care professional;

(4) the terms of coverage under the covered person's health care insurance policy with the health care insurer to ensure that the independent review organization decision is not contrary to the terms of coverage under the covered person's health care insurance policy with the health care insurer;

(5) the most appropriate practice guidelines that

(A) must include applicable evidence-based standards; and

(B) may include other practice guidelines developed by the federal government, national or professional medical societies, boards, and associations;

(6) the applicable clinical review criteria developed and used by the health care insurer or the health care insurer's designee utilization review organization; and

(7) the opinion of the independent review organization's clinical reviewer after considering the information or documents described in (1) - (6) of this subsection to the extent the information or documents are available and the clinical reviewer considers them appropriate.

(p) Not later than 45 days after receipt of the request for an external review, an assigned independent review organization shall provide written notice of the independent review organization's decision to uphold or reverse the adverse determination of the final adverse determination of a health care insurer to the covered person or the covered person's authorized representative, and also to the health care insurer and the director. In reaching a decision, the assigned independent review organization is not bound by a decision or conclusion reached during the health care insurer's utilization review or internal grievance processes. The notice under this subsection must include

(1) a general description of the reason for the request for external review;

(2) the date the independent review organization received the assignment from the director to conduct the external review;

(3) the date the external review was conducted;

(4) the date of the independent review organization's decision;

(5) each principal reason for the independent review organization's decision, including what applicable evidence-based standards, if any, were a basis for the decision;

(6) the rationale for the decision;

(7) references to evidence or documentation, including evidence-based standards, considered in reaching the decision; and

(8) the professional licenses held by each reviewer.

(q) Upon receipt of notice under (p) of this section of a decision of the independent review organization reversing the adverse determination or final adverse determination of the health care insurer, the health care insurer shall immediately approve the coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination or final adverse determination.

Notes

3 AAC 28.958

Eff. 3/15/2018,Register 225, April 2018

Authority:AS 21.06.090

AS 21.07.005