Section 41-6002 – DEFINITIONS.
41-6002. DEFINITIONS. [EFFECTIVE UNTIL JULY 1, 2024] As used in this chapter: (1) "Board" means the Idaho immunization assessment board created by section 41-6003, Idaho Code. (2) "Carrier" means: any entity subject to regulation by the department that provides or is authorized to provide health insurance or health benefit plans, or that administers health insurance […]
Section 41-5904 – APPLICABILITY AND SCOPE.
41-5904. APPLICABILITY AND SCOPE. (1) Except as provided in subsection (2) of this section, this chapter shall apply to all health carriers. (2) The provisions of this chapter shall not apply to a plan, policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage; nor shall this chapter apply […]
Section 41-5905 – NOTICE OF RIGHT TO EXTERNAL REVIEW.
41-5905. NOTICE OF RIGHT TO EXTERNAL REVIEW. (1) When a final adverse benefit determination is made, the health carrier shall notify the covered person in writing of the covered person’s right to request an external review to be conducted pursuant to section 41-5908, 41-5909 or 41-5910, Idaho Code, and include the appropriate statements and information […]
Section 41-5906 – REQUEST FOR EXTERNAL REVIEW.
41-5906. REQUEST FOR EXTERNAL REVIEW. A covered person may make a request for an external review of a final adverse benefit determination. Except for a request for an expedited external review as set forth in section 41-5909, Idaho Code, all requests for external review shall be made in writing to the director. The director may […]
Section 41-5907 – EXHAUSTION OF INTERNAL GRIEVANCE PROCESS.
41-5907. EXHAUSTION OF INTERNAL GRIEVANCE PROCESS. (1) Except as provided in subsection (2) of this section, a request for an external review pursuant to section 41-5908, 41-5909 or 41-5910, Idaho Code, shall not be made until the covered person has exhausted the health carrier’s internal grievance process. A covered person shall be considered to have […]
Section 41-5908 – STANDARD EXTERNAL REVIEW.
41-5908. STANDARD EXTERNAL REVIEW. (1) Within four (4) months after the date of issuance of a notice of a final adverse benefit determination pursuant to section 41-5905, Idaho Code, a covered person may file a request for an external review with the director. The request shall be made on such form as may be designated […]
Section 41-5909 – EXPEDITED EXTERNAL REVIEW.
41-5909. EXPEDITED EXTERNAL REVIEW. (1) A covered person may make a request for an expedited external review of a pre-service or concurrent service adverse benefit determination where the requested service meets the definition of an urgent care request and the covered person has exhausted the health carrier’s internal grievance process or is entitled to request […]
Section 41-5910 – BINDING NATURE OF EXTERNAL REVIEW DECISION.
41-5910. BINDING NATURE OF EXTERNAL REVIEW DECISION. (1) For a health care benefit plan not subject to the employee retirement income security act of 1974 (ERISA), the external review decision is final and binding on the health carrier and on the covered person. No judicial action or proceeding arising out of the external review decision […]
Section 41-5911 – APPROVAL OF INDEPENDENT REVIEW ORGANIZATIONS.
41-5911. APPROVAL OF INDEPENDENT REVIEW ORGANIZATIONS. (1) The director shall approve independent review organizations eligible to be assigned on a random basis to conduct external reviews under this chapter. (2) In order to be eligible for approval by the director under this section to conduct external reviews under this chapter an independent review organization shall: […]
Section 41-5912 – MINIMUM QUALIFICATIONS FOR INDEPENDENT REVIEW ORGANIZATIONS.
41-5912. MINIMUM QUALIFICATIONS FOR INDEPENDENT REVIEW ORGANIZATIONS. (1) To be approved to conduct external reviews, an independent 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) […]