Section Ins 2703.03 - The Right to External Review(a) A covered person shall have the right to independent external review of a determination by a health carrier or its designee utilization review entity when all of the following conditions apply: (1) The subject of the request for external review is an adverse determination;(2) The covered person or the covered person's authorized representative has submitted the request for external review in writing to the commissioner within 180 days of the date of the health carrier's final denial decision, or if the health carrier has failed to make a decision on appeal within the applicable time frame, then within180 days of the date the decision was due; and(3) The category of health care services or type of health benefit plan that is the subject of the request for external review is not excluded from the external review provisions of this rule pursuant to Ins 2703.02(b).(b) Benefit denials concerning requested health care services, supplies or drugs that could not be considered a covered benefit under any circumstance shall not be eligible for external review. However, a covered person may receive external review of a benefit denial if it is also an adverse determination.(c) A benefit denial which shall constitute an adverse determination includes, but is not limited to, the following: (1) Experimental or investigational treatments, where the health carrier denies requested care because the covered person's health benefit plan does not cover experimental or investigational treatment, but the covered person requests external review on the basis that the treatment in question is not experimental or investigational;(2) Cosmetic procedures, where the health carrier denies requested care because the covered person's health benefit plan does not cover cosmetic procedures, but the covered person requests external review on the basis that the service is needed for medical rather than cosmetic reasons; and(3) Access to out-of-network health care professionals or providers, where the health carrier denies a referral because treatment by out-of-network professionals or providers is not covered unless the appropriate clinical expertise is not available within the health carrier's network, but the covered person requests external review on the basis that the health carrier's provider network does not include professionals or providers with the appropriate clinical expertise.(d) In requesting external review, a covered person shall provide the following information:(1) The name of the covered person;(2) The covered person's mailing address, date of birth, telephone number and insurance identification number;(3) The employer's name and telephone number;(4) The carrier's name, mailing address, telephone number, and name of contact at the carrier;(5) The name of the provider, the type of provider, the provider's mailing address, and telephone number;(6) If applicable, the name, address and telephone number of the authorized representative and a signature giving the representative authority to represent the covered person;(7) If applicable, a request for a telephone conference;(8) A statement describing the health care decision in dispute;(9) A photocopy of the covered person's insurance card and certificate of coverage;(10) A copy of the final decision of the carrier denying the claim on internal review; and(11) A statement authorizing the release of the covered person's medical records.N.H. Admin. Code § Ins 2703.03
#7539, eff 8-1-01; ss by #8862, eff 5-1-07
Amended by Volume XXXV Number 36, Filed September 10, 2015, Proposed by #10918, Effective 9/1/2015, Expires9/1/2025.