054.00.76-10. External Review of Experimental or Investigational Treatment Adverse Determinatio...
AR ADC 054.00.76-10Arkansas Administrative Code
Ark. Admin. Code 054.00.76-10
054.00.76-10. External Review of Experimental or Investigational Treatment Adverse Determinations
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 that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a covered person or the covered person's authorized representative may file a request for external review with the Commissioner.
(2)(a) A covered person or the covered person's authorized representative may make an oral request for an expedited external review of the adverse determination or final adverse determination pursuant to (A)(1) under this Section 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.
(c)(i) Upon notice of the request for expedited external review, the health carrier immediately shall determine whether the request meets the reviewability requirements under (B) of this Section. 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.
(iii) The notice of initial determination under (A)(2)(c) (i) of this Section 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.
(e) Upon receipt of the notice that the expedited external review request meets the reviewability requirements of (B)(2) under this Section, the Commissioner immediately shall assign an independent review organization to review the expedited request from the list of approved independent review organizations compiled and maintained by the Commissioner pursuant to Section (12) of this Rule and notify the health carrier of the name of the assigned independent review organization.
(f) At the time the health carrier receives the notice of the assigned independent review organization pursuant to (A)(2)(e) 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.
(a) The individual is or was a covered person in the health benefit plan at the time the health care service or treatment was recommended or 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 or treatment was provided;
(ii) Who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat the covered person's condition, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the covered person that is the subject of the adverse determination or final adverse determination is likely to be more beneficial to the covered person than any available standard health care services or treatments;
(b) The notice of initial determination provided under (C)(2) of this Section 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 to conduct the external review from the list of approved independent review organizations compiled and maintained by the commissioner pursuant to Section (12) of this Rule and notify the health carrier of the name of the assigned independent review organization; and
(2) 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) of 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.
(4)(a) In selecting clinical reviewers pursuant to (D)(3)(a) of this Section, the assigned independent review organization shall select physicians or other health care professionals who meet the minimum qualifications described in Section (13) of this Rule and, through clinical experience in the past three (3)years, are experts in the treatment of the covered person's condition and knowledgeable about the recommended or requested health care service or treatment.
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 the final adverse determination.
(3)(a) If the health carrier or its designee utilization review organization has failed to provide the documents and information within the time specified in (E)(1) in 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) Each clinical reviewer selected pursuant to Subsection (D) under this Section shall review all of the information and documents received pursuant to Subsection (E) of this Section and any other information submitted in writing by the covered person or the covered person's authorized representative pursuant to (D)(2) 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)(2) of this Section, within one (1) business day after the receipt of the information, the assigned independent review organization shall forward the information to the health carrier.
(3) The external review may terminated only 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 recommended or requested health care service or treatment that is the subject of the adverse determination or final adverse determination.
(4)(a) Immediately upon 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, the covered person's authorized representative if applicable, the assigned independent review organization, and the commissioner in writing of its decision.
H.(1) Except as provided in (H)(3) of this Section, within twenty (20) days after being selected in accordance with Subsection (D) of this Section to conduct the external review, each clinical reviewer shall provide an opinion to the assigned independent review organization pursuant to subsection I on whether the recommended or requested health care service or treatment should be covered.
(b) A description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is more likely than not to be beneficial to the covered person than any available standard health care services or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments;
(3)(a) For an expedited external review, each clinical reviewer shall provide an opinion orally or in writing to the assigned independent review organization as expeditiously as the covered person's medical condition or circumstance requires, but in no event more than five (5) calendar days after being selected in accordance with Subsection (D) of this Section.
(b) If the opinion provided pursuant to (H)(3)(a) of this Section was not in writing, within forty-eight (48) hours following the date the opinion was provided, the clinical reviewer shall provide written confirmation of the opinion to the assigned independent review organization and include the information required under (H)(2) of this Section.
I. In addition to the documents and information provided pursuant to (A)(2) or (E) of this Section, each clinical reviewer selected pursuant to Subsection (D) of this Section, to the extent the information or documents are available and the reviewer considers appropriate, shall consider the following in reaching an opinion pursuant to Subsection (H) of this Section:
(4) The terms of coverage under the covered person's health benefit plan with the health carrier to ensure that, but for the health carrier's determination that the recommended or requested health care service or treatment that is the subject of the opinion is experimental or investigational, the reviewer's opinion is not contrary to the terms of coverage under the covered person's health benefit plan with the health carrier; and
(b) Medical or scientific evidence or evidence-based standards demonstrate that the expected benefits of the recommended or requested health care service or treatment is more likely than not to be beneficial to the covered person than any available standard health care service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments.
J.(1)(a) Except as provided in (J)(1)(b) of this Section, within twenty (20) days after the date it receives the opinion of each clinical reviewer pursuant to Subsection (I) of this Section, the assigned independent review organization, in accordance with (J)(2) of this Section, shall make a decision and provide written notice of the decision to:
(b)(i) For an expedited external review, within seventy-two (72) hours after the date it receives the opinion of each clinical reviewer pursuant to Subsection (I) under this Section, the assigned independent review organization, in accordance with (J)(2) of this Section, shall make a decision and provide notice of the decision orally or in writing to the persons listed in (J)(1)(a) under this Section.
(ii) If the notice provided under (J)(b)(i) under this Section was not in writing, within forty-eight (48) hours after the date of providing that notice, the assigned independent review organization shall provide written confirmation of the decision to the persons listed in (J)(1)(a) of this Section and include the information set forth in (J)(3).
(c)(i) If the clinical reviewers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the independent review organization shall obtain the opinion of an additional clinical reviewer in order for the independent review organization to make a decision based on the opinions of a majority of the clinical reviewers pursuant to (J)(2)(a) or (J)(2)(b) of this Section.
(4) Upon receipt of a notice of a decision pursuant to (J)(1) of this Section reversing the adverse determination or final adverse determination, the health carrier immediately shall approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination or final adverse determination.
L. 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 054.00.76-10, AR ADC 054.00.76-10
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