19 Miss. Code. R. 3-15.04 - Notice of Right to External Review

A.

1. A health carrier shall notify the covered person in writing of the covered person's right to request an external review to be conducted pursuant to Rule 15.07, Rule 15.08 or Rule 15.09 of this Regulation and include the appropriate statements and information set forth in subsection B at the same time the health carrier sends written notice of:

a. An adverse determination upon completion of the health carrier's utilization review process; and

b. A final adverse determination.

2. As part of the written notice required under paragraph (1), a health carrier shall include the following, or substantially equivalent, language: "We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for external review to the Office of the Insurance Commissioner, Mississippi Insurance Department, Attn: Life and Health Actuarial Division, P.O. Box 79, Jackson, MS 39205, Phone: (601) 359-3569."

3. The Notice of Appeal Rights, attached hereto as Rule 15.20 - Appendix "A" meets all form and content requirements of this section.

B.

1. The health carrier shall include in the notice required under subsection A:

a. For a notice related to an adverse determination, a statement informing the covered person that:

i. If the covered person has a medical condition where the timeframe for completion of an expedited 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, the covered person or the covered person's authorized representative may file a request for an expedited external review to be conducted pursuant to Rule 15.08 of this Regulation, or Rule 15.09 of this Regulation if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated, at the same time the covered person or the covered person's authorized representative files a request for an expedited review of a grievance involving on adverse determination, but that the independent review organization assigned to conduct the expedited external review will determine whether the covered person shall be required to complete the expedited review of the grievance prior to conducting the expedited external review; and

ii. The covered person or the covered person's authorized representative may file a grievance under the health carrier's internal grievance process, but if the health carrier has not issued a written decision to the covered person or the covered person's authorized representative within thirty (30) days following the date the covered person or the covered person's authorized representative files the grievance with the health carrier and the covered person or the covered person's authorized representative has not requested or agreed to a delay, the covered person or the covered person's authorized representative may file a request for external review pursuant to Rule 15.05 of this Regulation and shall be considered to have exhausted the health carrier's internal grievance process for purposes of Rule 15.06 of this Regulation; and

b. For a notice related to a final adverse determination, a statement informing the covered person that:

i. If the covered person has a medical condition where the timeframe for completion of a standard external review pursuant to Rule 15.07 of this Regulation would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person or the covered person's authorized representative may file a request for an expedited external review pursuant to Rule 15.08 of this Regulation; or

ii. If the final adverse determination concerns:

I. An admission, availability of care, continued stay or health care service for which the covered person received emergency services, but has not been discharged from a facility, the covered person or the covered person's authorized representative may request an expedited external review pursuant to Rule 15.08 of this Regulation; or

II. A denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational, the covered person or the covered person's authorized representative may file a request for a standard external review to be conducted pursuant to Rule 15.07 of this Regulation or if the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated, the covered person or the covered person's authorized representative may request an expedited external review to be conducted under Rule 15.08 of this Regulation.

2. In addition to the information to be provided pursuant to paragraph (1), the health carrier shall include a copy of the description of both the standard and expedited external review procedures the health carrier is required to provide pursuant to Rule 15.16 of this Regulation, highlighting the provisions in the external review procedures that give the covered person or the covered person's authorized representative the opportunity to submit additional information and including any forms used to process an external review.

3. As part of any forms provided under paragraph (2), the health carrier shall include an authorization form, or other document approved by the Commissioner that complies with the requirements of 45 CFR Section 164.508, by which the covered person, for purposes of conducting an external review under this Regulation, authorizes the health carrier and the covered person's treating health care provider to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review.

Notes

19 Miss. Code. R. 3-15.04

Miss. Code Ann. § 83-5-1 (Rev. 2011); Public Law 111-148 -Mar. 23, 2010 (Patient Protection and Affordable Care Act)

Adopted 4/15/2015