054.00.76-8. Standard External Review
AR ADC 054.00.76-8Arkansas Administrative Code
Ark. Admin. Code 054.00.76-8
054.00.76-8. Standard External Review
(2) The health care service that is the subject of the adverse determination or the final adverse determination is a covered service under the covered person's health benefit plan, but for a determination by the health carrier that the health care service is not covered because it does not meet the health carrier's requirements for medical necessity (or substantially equivalent term), appropriateness, health care setting, level of care or effectiveness;
(b) The notice of initial determination shall include a statement informing the covered person and, if applicable, the covered person's authorized representative that a health carrier's initial determination that the external review request is ineligible for review may be appealed to the Commissioner.
(a) Assign an independent review organization from the list of approved independent review organizations compiled and maintained by the Commissioner pursuant to Section (12) of this Rule to conduct the external review and notify the health carrier of the name of the assigned independent review organization; and
(3) The Commissioner shall include in the notice provided to the covered person and, if applicable, the covered person's authorized representative a statement that the covered person or the covered person's authorized representative may submit in writing to the assigned independent review organization within five (5) business days following the date of receipt of the notice provided pursuant to (D)(1) under this Section additional information that the independent review organization shall consider when conducting the external review. The independent review organization is not required to, but may, accept and consider additional information submitted after five (5) business days.
E.(1) Within five (5) business days after the date of receipt of the notice provided pursuant to (D)(1) of this Section, the health carrier or its designee utilization review organization shall provide to the assigned independent review organization the documents and any information considered in making the adverse determination or final adverse determination.
(3)(a) If the health carrier or its utilization review organization fails to provide the documents and information within the time specified in (E)(1) of this Section, the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination.
F.(1) The assigned independent review organization shall review all of the information and documents received pursuant to Subsection (E) under this Section and any other information submitted in writing to the independent review organization by the covered person or the covered person's authorized representative pursuant to (D)(3) of this Section.
(3) The external review may only be terminated if the health carrier decides, upon completion of its reconsideration, to reverse its adverse determination or final adverse determination and provide coverage or payment for the health care service that is the subject of the adverse determination or final adverse determination.
(4)(a) Within one (1) business day after making the decision to reverse its adverse determination or final adverse determination, as provided in (G)(3) of this Section, the health carrier shall notify the covered person, if applicable, the covered person's authorized representative, the assigned independent review organization, and the commissioner in writing of its decision.
H. In addition to the documents and information provided pursuant to Subsection (E) under this Section, the assigned independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision:
J. The assignment by the Commissioner of an approved independent review organization to conduct an external review in accordance with this section shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the health care service that is the subject of the adverse determination or final adverse determination and other circumstances, including conflict of interest concerns pursuant to Section (13)(D) of this Rule.
Credits
Amended Jan. 6, 2012.
Current with amendments received through May 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.76-8, AR ADC 054.00.76-8
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