054.00.76-5. Notice of Right to External Review
AR ADC 054.00.76-5Arkansas Administrative Code
Ark. Admin. Code 054.00.76-5
054.00.76-5. 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 Sections 8, 9 or 10 of this Rule and include the appropriate statements and information set forth in Subsection (B) of this Section at the same time the health carrier sends written notice of:
(2) As part of the written notice required under Subsection (A) of this Section 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 (or substantially equivalent term), 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 in writing to the Arkansas Insurance Commissioner at 1200 West 3rd Street, Little Rock, AR 72201 or by calling 1-800-282-9134.”
(i) If the covered person has a medical condition where the time frame for completion of an expedited review of an appeal involving an adverse determination set forth in the health carrier's internal appeal procedure or utilization review procedure 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 Section 9 of this Rule, or Section 10 of this Rule 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 an appeal involving an adverse determination as set forth in the health carrier's internal appeal procedure or utilization review procedure, 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 appeal prior to conducting the expedited external review; and
(ii) The covered person or the covered person's authorized representative may file an appeal under the health carrier's internal appeal 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 appeal with the health carrier for a pre-service claim or sixty (60) days for a post-service claim 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 Section 6 of this Rule and shall be considered to have exhausted the health carrier's internal appeal process for purposes of Section 7 of this Rule; and
(i) If the covered person has a medical condition where the timeframe for completion of a standard external review pursuant to Section (8) of this Rule 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 section 9 of this Rule; or
(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 section 9 of this Rule; 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 Section 10 of this Rule 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 Section 10 of this Rule.
(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 Section 17 of this Rule, 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 Rule, 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.
Credits
Amended Jan. 6, 2012.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.76-5, AR ADC 054.00.76-5
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