054.00.76-9. Expedited External Review
AR ADC 054.00.76-9Arkansas Administrative Code
Ark. Admin. Code 054.00.76-9
054.00.76-9. Expedited External Review
(a) The adverse determination involves a medical condition of the covered person for which the timeframe for completion of an expedited internal 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; and
(2) Immediately upon receipt of the request pursuant to (B)(1) of this Section, the health carrier shall determine whether the request meets the reviewability requirements set forth in Section (8)(B) of this Rule. The health carrier shall immediately notify the Commissioner and the covered person and, if applicable, the covered person's authorized representative of its eligibility determination.
(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 an external review request is ineligible for review may be appealed to the Commissioner.
(5) Upon receipt of the notice that the request meets the reviewability requirements, the commissioner immediately shall assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations compiled and maintained by the Commissioner pursuant to Section (12) of this Rule. The Commissioner shall immediately notify the health carrier of the name of the assigned independent review organization.
C. Upon receipt of the notice from the Commissioner of the name of the independent review organization assigned to conduct the expedited external review pursuant to (B)(5) of this Section, the health carrier or its designee utilization review organization shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization electronically or by telephone or facsimile or any other available expeditious method.
D. In addition to the documents and information provided or transmitted pursuant to Subsection (C) of 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:
E.(1) As expeditiously as the covered person's medical condition or circumstances requires, but in no event more than seventy-two (72) hours after the date of receipt of the request for an expedited external review that meets the reviewability requirements set forth in Section (8)(B) of this Rule, the assigned independent review organization shall:
G. 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 February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.76-9, AR ADC 054.00.76-9
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