3 AAC 28.978 - External review reporting requirements

(a) An independent review organization assigned to conduct an external review shall maintain written records, in the aggregate by state and by health care insurer, of requests for external review for which the independent review organization conducted external reviews during a calendar year.

(b) An independent review organization required to maintain written records under this section shall submit to the director, upon request, a report in a format specified by the director. The report must include

(1) the name and mailing address of the independent review organization;

(2) the name, title, electronic mail address, telephone number, and facsimile transmission number of the person completing die report;

(3) the name, title, electronic mail address, telephone number, and facsimile transmission number of the person responsible for regulatory compliance and quality of external reviews; and

(4) in the aggregate by state and by health care insurer the following:

(A) the total number of requests assigned to the independent review organization for

(i) standard external reviews; and

(ii) expedited external reviews;

(B) the average length of time for resolution of requests for external review assigned to the independent review organization for

(i) standard external reviews; and

(ii) expedited external reviews;

(C) the number of medical necessity external reviews decided in favor of a health care insurer and a brief list of the procedures denied;

(D) the number of medical necessity external reviews decided in favor of the covered person and a brief list of the procedures approved;

(E) the number of experimental or investigational treatment external reviews decided in favor of the health care insurer and a brief list of the procedures denied:

(F) the number of experimental or investigational treatment external reviews decided in favor of the covered person and a brief list of the procedures approved;

(G) the number of external reviews terminated as the result of a reconsideration by a health care insurer;

(H) the number of external reviews terminated by the covered person or the covered person's authorized representative before issuance by the independent review organization of the external review decision;

(I) the number of external reviews declined due to possible conflict of interest for each of the following:

(i) a health care insurer;

(ii) a covered person;

(iii) a health care provider;

(J) a brief description of the conflicts of interest identified under (I)(i) -(iii) of this paragraph;

(K) the number of external reviews declined due to other reasons not reflected under (I) of this paragraph.

(c) The independent review organization shall provide to the director documents or information requested by the director not later than five working days after receipt of the request,

(d) The independent review organization shall retain the written records required under this section for at least three years.

(e) A health care insurer shall maintain written records in the aggregate by state and by type of health care insurance policy offered by the health care insurer of all requests for external review that the health care insurer receives notice of from the director under 3 AAC 28.950 - 3 AAC 28.982,

(f) A health care insurer required to maintain written records under this section shall submit to the director, upon request, a report in the format specified by the director. The report must include the following:

(1) the name and mailing address of the health care insurer;

(2) the name, title, electronic mail address, telephone number, and facsimile transmission number of the person completing the report;

(3) the name, title, electronic mail address, telephone number, and facsimile transmission number of the person responsible for regulatory compliance; and

(4) in the aggregate, by state and by type of health plan offered, the following:

(A) the total number of requests for external review of the health cure insurer's adverse determinations and final adverse determinations;

(B) the number of requests determined eligible for external review;

(C) the number of requests for external review resolved and, of those resolved,

(i) the number upholding the adverse determination or final adverse determination of the health care insurer; and

(ii) the number reversing the adverse determination or final adverse determination of the health care insurer; and

(D) the number of external reviews that were terminated as the result of reconsideration by the health care insurer of an adverse determination or final adverse determination after the receipt of additional information from the covered person or the covered person's authorized representative.

(g) A health care insurer shall provide the director with other requested documents or information not later than five working days after receipt of the request.

(h) A health care insurer shall retain the written records required under this section for at least three years.

(i) A health care insurer shall ensure the health care insurer's person responsible for regulatory compliance identified under (f)(3) of this section or the person's designated alternate is available to the director during the division's normal working hours, 8:00 a.m. to 4:30 p.m., Alaska time zone, Monday through Friday, excluding state holidays.

Notes

3 AAC 28.978

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

Authority:AS 21.06.090

AS 21.07.005