Expedited reviews of grievances involving an adverse determination
See bold text below:
(a) A health care insurer shall establish written procedures for the expedited review of an urgent care request of a grievance involving an adverse determination. The procedures must allow a covered person or the covered person’s authorized representative to request an expedited review under this section orally or in writing.
(b) In addition to (a) of this section, a health care insurer shall provide expedited review of a grievance involving an adverse determination with respect to a concurrent review urgent care request involving
(1) an admission;
(2) availability of care;
(3) a continued stay; or
(4) a health care service for a covered person who has received emergency services but has not been discharged from a facility.
(c) A health care insurer shall appoint an appropriate clinical peer or peers, in the same or similar specialty as would typically manage the case being reviewed, to review the adverse determination. A health care insurer may not designate a person involved in making the initial adverse determination to be a clinical peer.
(d) In an expedited review, a health care insurer shall transmit all necessary information, including the health care insurer’s decision, to a covered person or the covered person’s authorized representative by telephone, facsimile transmission, electronic mail, or the most expeditious method available.
Medical Necessity Decisions-Deadlines
(e) A health care insurer shall make an expedited review decision and shall notify a covered person or the covered person’s authorized representative of the decision under (h) of this section as expeditiously as the covered person’s medical condition requires, but not later than 72 hours after the receipt of the request for the expedited review.
(f) If an expedited review is of a grievance involving an adverse determination with respect to a concurrent review urgent care request, a health care insurer shall continue coverage of the services without liability to a covered person until the covered person or the covered person’s authorized representative is notified of the determination.
(g) The time period within which a decision is required to be made under (e) of this section begins on the date a request is filed with a health care insurer under the health care insurer’s procedures established under 3 AAC 28.934 for filing a request, without regard to whether all of the information necessary to make the determination accompanies the filing.
(h) Except for 3 AAC 28.936(o)(7), the requirements under 3 AAC 28.936(o) – (q), for the review of a grievance involving an adverse determination, apply to an expedited review of a grievance involving an adverse determination. An expedited review of a grievance involving an adverse determination notice must include a description of additional material or information necessary for a covered person or the covered person’s authorized representative to complete a request, including an explanation of why the material or information is necessary to complete the request.