Notice requirements — Process for appealing adverse determination and restriction or denial of healthcare service
See bold test below:
(1) Notice of an adverse determination shall be provided to the healthcare provider that initiated the prior authorization.
(2) Notice may be made by electronic mail, fax, or hard copy letter sent by regular mail, or verbally, as requested by the subscriber’s healthcare provider.
(b) The written or verbal notice required under this section shall include:
(1) The following information:
(A) The name, title, and telephone number of the physician responsible for making the adverse determination and, in the event that the physician responsible for making the adverse decision is not available, a telephone number where a peer-to-peer contact with another physician regarding the adverse determination can be made;
(B) The reviewing physician’s board certification status or board eligibility; and
(C) A list of states in which the reviewing physician is licensed and the license number issued to the reviewing physician by each state;
(2) The written clinical criteria, if any, and any internal rule, guideline, or protocol on which the utilization review entity relied when making the adverse determination and how those provisions apply to the subscriber’s specific medical circumstance;
(3) Information for the subscriber and the subscriber’s healthcare provider that describes the procedure through which the subscriber or healthcare provider may request a copy of any report developed by personnel performing the review that led to the adverse determination; and
(A) Information that explains to the subscriber and the subscriber’s healthcare provider the right to appeal the adverse determination.
(B) The information required under subdivision (b)(4)(A) of this section shall include:
(i) Instructions concerning how to perfect an appeal and how the subscriber and the subscriber’s healthcare provider may ensure that written materials supporting the appeal will be considered in the appeal process; and
(a) Addresses and telephone numbers to be used by healthcare providers and subscribers to make complaints to the Arkansas State Medical Board, the State Board of Health, and the State Insurance Department.
(b) Subdivision (b)(4)(B)(ii)(a) of this section does not apply to self-insured plans for employees of governmental entities.
Step Therapy Override
(1) When a healthcare service for the treatment or diagnosis of any medical condition is restricted or denied in favor of step therapy or a fail first protocol preferred by the utilization review entity, the subscriber’s healthcare provider shall have access to a clear and convenient process to expeditiously request an override of that restriction or denial from the utilization review entity or healthcare insurer.
(2) Upon request, the subscriber’s healthcare provider shall be provided contact information, including a phone number, for a person to initiate the request for an expeditious override of the restriction or denial.
(d) The appeal process described in subdivision (b)(4) of this section shall not apply when a healthcare service is denied because the healthcare service is within a category of healthcare services not covered by the health benefit plan.