3 AAC 28.960 - Expedited external review

(a) Except under (k) of this section, a covered person or the covered person's authorized representative may make an oral or written request to the director for an expedited external review of a health care insurer's adverse determination or final adverse determination when the covered person or the covered person's authorized representative receives

(1) an adverse determination that

(A) involves a medical condition of the covered person for which the time frame for completion of an expedited internal review of a grievance involving an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; and

(B) the covered person or the covered person's authorized representative has filed a request for an expedited review of a grievance involving an adverse determination; or

(2) a final adverse determination that

(A) involves a medical condition where the time frame for completion of a standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; or

(B) concerns emergency or health care services, for which the covered person has not been discharged from a facility, including

(A) an admission;

(B) availability of care;

(C) a continued stay; or

(D) a health care service or treatment.

(b) Upon receipt of a request for an expedited external review, the director will immediately send written notice of the request to the health care insurer.

(c) Immediately upon receipt of notice of a request for expedited external review under (b) of this section, a health care insurer shall complete a preliminary review of the request to determine whether the request meets the eligibility requirements for external review under 3 AAC 28.958(d). If the health care insurer determines that the request is not eligible for external review, the health care insurer shall immediately 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 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.

(d) 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 3 AAC 28.958(d) 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.

(e) Upon receipt of notice of initial determination from a health care insurer that a request is eligible for expedited external review or upon a determination by the director that a request is eligible for expedited external review, the director will immediately

(1) assign an independent review organization, in the manner set out in 3 A AC 28.958(i)(I), to conduct the expedited external review; and

(2) notify the health care insurer and notify the covered person or the covered person's authorized representative of the name of the assigned independent review organization.

(f) Upon receiving notice under (e)(2) of this section, a health care insurer or the health care insurer's designee utilization review organization shall immediately provide or transmit, by electronic mail, telephone, facsimile transmission, or other available expeditious method, all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization.

(g) In addition to the documents and information provided to an assigned independent review organization under (f) of this section, the assigned independent review organization shall, to the extent the information or documents are available and the independent review organization considers them appropriate, consider the information and documents described in 3AAC 28.958(o)(1)-(7).

(h) As expeditiously as the covered person's medical condition or circumstances require, but not later than 72 hours after receipt of an eligible request for expedited external review, an assigned independent review organization shall

(1) make a decision to uphold or reverse the adverse determination or final adverse determination of the health care insurer; in reaching a decision, the assigned independent review organization is not hound by the decision or conclusion reached during the health care insurer's utilization review or internal grievance processes; and

(2) notify the covered person or the covered person's authorized representative, and also notify the health care insurer and the director, of the decision.

(i) If the notice provided under (h) of this section is not in writing, not later than 48 hours after providing that notice, an assigned independent review organization shall provide written confirmation of the decision to the covered person or the covered person's authorized representative, and also to the health care insurer and the director. The written confirmation must include the information set out in 3 AAC 28.958(p)(1) - (8).

(j) Upon receipt of notice of a decision of the independent review organization reversing the adverse determination or final adverse determination of the health care insurer under (h) of this section, 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.

(k) The director will reject a request for an expedited external review of a retrospective adverse or final adverse determination.

Notes

3 AAC 28.960

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

Authority:AS 21.06.090

AS 21.07.005