A.(1) Within four (4) months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to Section (5) of this Rule, a covered person or the covered person's authorized representative may file a request for an external review with the Commissioner.

(2) Within one (1) business day after the date of receipt of a request for external review pursuant to (A) (1) under this Section, the Commissioner shall send a copy of the request to the health carrier.

(1) The individual is or was a covered person in the health benefit plan at the time the health care service was requested or, in the case of a retrospective review, was a covered person in the health benefit plan at the time the health care service was provided;

(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;

(3) The covered person has exhausted the health carrier's internal appeal process unless the covered person is not required to exhaust the health carrier's internal appeal process pursuant to Section (7) of this Rule; and

(4) The covered person has provided all the information and forms required to process an external review, including the release form provided under Section (5)(B) of this Rule.

C.(1) Within one (1) business day after completion of the preliminary review, the health carrier shall notify the commissioner and covered person and, if applicable, the covered person's authorized representative in writing whether:

(2) If the request:

D.(1) Whenever the Commissioner receives a notice that a request is eligible for external review following the preliminary review conducted pursuant to subsection (C) under this Section, within one (1) business day after the date of receipt of the notice, the Commissioner shall:

(2) In reaching a decision, the assigned independent review organization is not bound by any decisions or conclusions reached during the health carrier's utilization review process or the health carrier's internal appeal process.

(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.

(2) Except as provided in (E)(3) under this Section, failure by the health carrier or its utilization review organization to provide the documents and information within the time specified in (E)(1) of this Section shall not delay the conduct of the external review.

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.

(2) Upon receipt of any information submitted by the covered person or the covered person's authorized representative pursuant to subsection (D)(3) under this Section, the assigned independent review organization shall within one (1) business day forward the information to the health carrier.

G.(1) Upon receipt of the information, if any, required to be forwarded pursuant to subsection (F)(2) of this Section, the health carrier may reconsider its adverse determination or final adverse determination that is the subject of the external review.

(2) Reconsideration by the health carrier of its adverse determination or final adverse determination pursuant to (G)(1) under this Section shall not delay or terminate the external review.

(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.

(1) The covered person's medical records;

(2) The attending health care professional's recommendation;

(3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, the covered person's authorized representative, or the covered person's treating provider;

(4) The terms of coverage under the covered person's health benefit plan with the health carrier to ensure that the independent review organization's decision is not contrary to the terms of coverage under the covered person's health benefit plan with the health carrier;

(5) The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or professional medical societies, boards and associations;

(6) Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review organization; and

(7) The opinion of the independent review organization's clinical reviewer or reviewers after considering paragraphs (H)(1) through (H)(6) of this Section to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.

I.(1) Within forty-five (45) days after the date of receipt of the request for an external review, the assigned independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to:

(2) The independent review organization shall include in the notice sent pursuant to (I)(1) of this Section:

(3) Upon receipt of a notice of a decision pursuant to paragraph (I)(1) of this Section reversing the adverse determination or final adverse determination, the health carrier immediately shall approve the coverage that was the subject of the adverse determination or final adverse determination.