§ 991.2164d. Exhaustion of internal appeal process
Purdon's Pennsylvania Statutes and Consolidated StatutesTitle 40 P.S. InsuranceEffective: January 1, 2024
Effective: January 1, 2024
40 P.S. § 991.2164d
§ 991.2164d. Exhaustion of internal appeal process
(ii) Except to the extent the covered person or the covered person's authorized representative requested or agreed to a delay, has not received a written decision on the appeal from the insurer within 30 days following the date the covered person or the covered person's authorized representative filed the appeal with the insurer.
(iv) The insurer has failed to comply with the requirements of the internal claim and appeal process unless the failure or failures are based on de minimis violations that do not cause, and are not likely to cause, prejudice or harm to the covered person or covered person's authorized representative.
(1) At the same time a covered person or the covered person's authorized representative files a request for expedited internal review of an adverse benefit determination under section 2164, the covered person or the covered person's authorized representative may file a request for an expedited external review of the adverse benefit determination:
(i) Under section 2164.6, if the covered person has a medical condition for which the time frame for completion of an expedited internal review of the adverse benefit determination under section 2164 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function.
(ii) Under section 2164.7, if the adverse benefit determination involves a denial of coverage based on a determination that the recommended or requested health care service is experimental or investigational, and the covered person's treating health care provider certifies in writing that the recommended or requested health care service that is the subject of the adverse benefit determination would be significantly less effective if not promptly initiated.
(2) Upon receipt of a request for an expedited external review under paragraph (1), the IRO conducting the external review under section 2164.6 or 2164.7 shall determine whether the covered person is required to complete the expedited internal review process under section 2164 before the IRO conducts the expedited external review.
(c) Denial of request for expedited external review.--If the IRO determines that the covered person is required to first complete the internal expedited appeal process under section 2164, the IRO shall within 24 hours notify the covered person and, if applicable, the covered person's authorized representative that the IRO may not proceed with the expedited external review under section 2164.6 until the insurer has completed the expedited review process and the covered person's adverse benefit determination appeal remains unresolved.
(d) Waiver of exhaustion requirement.--A request for external review of an adverse benefit determination may be made before the covered person has exhausted the insurer's internal appeal procedures under section 2164, if the insurer agrees to waive the exhaustion requirement. At that time, the covered person or the covered person's authorized representative may file a request in writing for standard external review as provided in section 2164.5 or 2164.7.
Credits
1921, May 17, P.L. 682, No. 284, § 2164.4, added 2022, Nov. 3, P.L. 2068, No. 146, § 7, effective Jan. 1, 2024.
40 P.S. § 991.2164d, PA ST 40 P.S. § 991.2164d
Current through Act 10 of the 2024 Regular Session. Some statute sections may be more current, see credits for details.
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