§ 56-61-116. Standard External Review
Within six (6) months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to § 56-61-113, an aggrieved person may file a request for an external review with the health carrier. Within ten (10) business days following the date of receipt of the copy of the external […]
§ 56-61-117. Expedited External Review
Except as provided in subsection (f), an aggrieved person may make a request for an expedited external review with the health carrier at the time the aggrieved person receives: An adverse determination if: The adverse determination involves a medical condition of the covered person for which the timeframe for completion of an expedited internal review […]
§ 56-61-118. Requests for External Review When Service or Treatment Determined to Be Investigational
Within six (6) months after the date of receipt of a notice of an adverse determination or final adverse determination that involves a denial of coverage based on a determination that the healthcare service or treatment recommended or requested is investigational, an aggrieved person may file a request for external review with the health carrier. […]
§ 56-61-119. Binding Nature of External Review Decisions
An external review decision is binding on the health carrier except to the extent that the health carrier has other remedies available under applicable federal or state law. An external review decision is binding on the covered person except to the extent that the covered person has other remedies available under applicable federal or state […]
§ 56-61-120. Approval of External Review Organizations
The commissioner shall approve external review organizations eligible to conduct external reviews under this chapter. In order to be eligible for approval by the commissioner to conduct external reviews under this chapter, an external review organization: Except as otherwise provided in this section, shall be accredited by a nationally recognized private accrediting entity that the […]
§ 56-61-121. Minimum Qualifications for Independent Review Organizations
To be approved under § 56-61-120 to conduct external reviews, an external review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in this chapter that include, at a minimum: A quality assurance mechanism in place […]
§ 56-61-122. Hold Harmless for External Review Organizations
No external review organization or clinical reviewer working on behalf of an external review organization or an employee, agent or contractor of an external review organization shall be liable in damages to any person for any opinions rendered or acts or omissions performed within the scope of the organization’s or person’s duties under the law […]
§ 56-61-123. External Review Reporting Requirements
An external review organization conducting an external review pursuant to this chapter shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it conducted an external review during a calendar year and, upon request, submit a report to the commissioner, as required under subdivision […]
§ 56-61-124. Funding of External Review
The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the cost of the external review organization for conducting the external review.
§ 56-61-125. Disclosure Requirements
Each health carrier shall include a description of the external review procedures in or attached to the membership booklet, provider manual, and health carrier’s web site. The health carrier may include a description of the external review procedures in the policy, certificate, outline of coverage, or other evidence of coverage provided to covered persons and […]