Chapter 20:06:53 - External and internal review
- Section 20:06:53:01 - Definitions
- Section 20:06:53:02 - Applicability
- Section 20:06:53:03 - Notice of right to external review
- Section 20:06:53:04 - Content of notices
- Section 20:06:53:05 - Review procedures and authorization to accompany notice
- Section 20:06:53:06 - Request for external review
- Section 20:06:53:07 - Exhaustion of internal grievance process required
- Section 20:06:53:08 - When exhaustion of internal grievance occurs
- Section 20:06:53:09 - Request for expedited review
- Section 20:06:53:10 - Determination of expedited review
- Section 20:06:53:11 - Waiver of exhaustion requirement
- Section 20:06:53:12 - Standard external review
- Section 20:06:53:13 - Notification following preliminary review
- Section 20:06:53:14 - Determination by the director and assignment of independent review organization
- Section 20:06:53:15 - Independence of review decision
- Section 20:06:53:16 - Health carrier required to provide information
- Section 20:06:53:17 - Effect of failure to act on external review process
- Section 20:06:53:18 - Independent review organization review of information
- Section 20:06:53:19 - Carrier reconsideration
- Section 20:06:53:20 - Information to be considered by independent review organization
- Section 20:06:53:21 - Independent review organization decisions
- Section 20:06:53:22 - Director assignment of independent review organization
- Section 20:06:53:23 - Expedited external review
- Section 20:06:53:24 - Notifications upon request for expedited external review
- Section 20:06:53:25 - Director's determination of eligibility for expedited reviews
- Section 20:06:53:26 - Director assignment of independent review organization for expedited reviews
- Section 20:06:53:27 - Independent review organization decision for expedited reviews
- Section 20:06:53:28 - Information to be considered by independent review organization for expedited review
- Section 20:06:53:29 - Expedited review decision
- Section 20:06:53:30 - Health carrier required to approve upon reversal by expedited review
- Section 20:06:53:31 - Assignment of independent review organization for expedited reviews
- Section 20:06:53:32 - Applicability of expedited reviews
- Section 20:06:53:33 - External review of experimental or investigational treatment adverse determinations
- Section 20:06:53:34 - Notifications upon request for external review of experimental or investigational treatment adverse determinations
- Section 20:06:53:35 - Director's determination of eligibility and assignment for external review of experimental or investigational treatment
- Section 20:06:53:36 - Health carrier preliminary review of request for experimental or investigational treatment reviews
- Section 20:06:53:37 - Health carrier notification after preliminary review of request for experimental or investigational treatment reviews
- Section 20:06:53:38 - Director's determination of request for experimental or investigational treatment reviews
- Section 20:06:53:39 - Health carrier notification of eligibility for experimental or investigational treatment reviews
- Section 20:06:53:40 - Independent review organization experimental or investigational treatment reviews
- Section 20:06:53:41 - Independent review organization clinical reviewer written opinion for experimental or investigational treatment reviews
- Section 20:06:43:42 - Records provided to independent review organization for experimental or investigational treatment reviews
- Section 20:06:53:43 - Review of information by independent review organization for experimental or investigational treatment reviews
- Section 20:06:53:44 - Reconsideration by health carrier for experimental or investigational treatment reviews
- Section 20:06:53:45 - Clinical review opinion for experimental or investigational treatment reviews
- Section 20:06:53:46 - Expedited review opinions for experimental or investigational treatment reviews
- Section 20:06:53:47 - Clinical review criteria for experimental or investigational treatment reviews
- Section 20:06:53:48 - Independent review organization decision and notice for experimental or investigational treatment reviews
- Section 20:06:53:49 - Expedited reviews upon receipt of clinical review opinion for experimental or investigational treatment reviews
- Section 20:06:53:50 - Decision by independent review organization for experimental or investigational treatment reviews
- Section 20:06:53:51 - Notice of written decision by independent review organization for experimental or investigational treatment reviews
- Section 20:06:53:52 - Health carrier requirement upon notice of decision reversing adverse determination for experimental or investigational treatment reviews
- Section 20:06:53:53 - Criteria for assignment of independent review organization for experimental or investigational treatment reviews
- Section 20:06:53:54 - Binding nature of external review decision
- Section 20:06:53:55 - Approval of independent review organizations
- Section 20:06:53:56 - Continuation of approval for independent review organizations
- Section 20:06:53:57 - Minimum qualifications for independent review organizations
- Section 20:06:53:58 - Requirements for clinical reviewers
- Section 20:06:53:59 - Subsidiaries of or ownership in independent review organizations
- Section 20:06:53:60 - Independence of clinical reviewers
- Section 20:06:53:61 - Nationally accredited independent review organizations
- Section 20:06:53:62 - Unbiased independent review organization
- Section 20:06:53:63 - Hold harmless for independent review organizations
- Section 20:06:53:64 - External review reporting requirements
- Section 20:06:53:65 - Independent review organization and health carrier recordkeeping
- Section 20:06:53:66 - Funding of external review
- Section 20:06:53:67 - Disclosure requirements
- Section 20:06:53:68 - Adverse benefit determination - Defined
- Section 20:06:53:69 - Urgent care requests - Timely notification of determination - Initial benefit determination
- Section 20:06:53:70 - Additional evidence
- Section 20:06:53:71 - Avoiding conflicts of interest
- Section 20:06:53:72 - Notice to enrollee
- Section 20:06:53:73 - Failure to comply with internal claims and appeal process
- Section 20:06:53:74 - Continued coverage and ongoing treatment
- Section 20:06:53:75 - One level of internal appeals
- Section 20:06:53:76 - Record keeping
- Section 20:06:53:77 - Applicability
- Section 20:06:53:78 - Strictly adhere - Defined
- Section 20:06:53:79 - Written explanation of violation
- Section 20:06:53:80 - Procedure when immediate review request denied
- Appendix A - Model notice of appeal rights
- Appendix B - Model external review request form
- Appendix C - Independent review organization external review annual report form
- Appendix D - Model health carrier external review annual report form