Section Ins 2703.05 - Standard External Review Standard external review shall be conducted as follows:
(a) Within 7 business days after the date of receipt of a request for external review, the department shall complete a preliminary review of the request to determine whether: (1) The individual is or was a covered person under the health benefit plan;(2) The determination that is the subject of the request for external review meets the conditions of eligibility for external review stated in Ins 2703.03(a); and(3) The covered person has provided all the information and forms that are necessary to process a request for an external review.(b) Upon completion of the preliminary review pursuant to Ins 2703.05(a), the department shall immediately notify the covered person or the covered person's authorized representative in writing: (1) Whether the request is complete; and(2) Whether the request has been accepted for external review.(c) If the request is not complete, the department shall inform the covered person or the covered person's authorized representative what information or documents are needed to make the request complete and to process the request. The covered person or the covered person's authorized representative shall submit such information or documentation within 10 days of being notified that the request was incomplete.(d) If the request for external review is accepted, the department shall: (1) Notify the covered person that new or additional information can be submitted to the insurance department;(2) Notify the covered person that oral testimony shall be permitted only when the commissioner determines, based on evidence provided by the covered person, that it would not be feasible or appropriate to present only written testimony;(3) Notify the covered person that the request for a hearing shall be made no less than 10 days after the date of issuance of the notice of acceptance;(4) Notify the covered person that if the request for oral testimony is accepted that oral testimony shall be taken within 20 days of the date of notice of acceptance and that a representative of the health carrier shall be permitted to participate in the hearing or teleconference; and(5) Notify the health carrier in writing of the request for external review and its acceptance, and provide the health carrier with a copy of the request and of any supporting documentation submitted by the covered person or the covered person's authorized representative.(e) If the request for external review is not accepted, the department shall inform the covered person or the covered person's authorized representative and the health carrier in writing of the reason for its non-acceptance.(f) At the time a request for external review is accepted, the commissioner shall select and retain an independent review organization that is certified pursuant to Ins 2703.07 to conduct the external review.(g) Within 10 days after the date of issuance of the notice provided pursuant to Ins 2703.05(b)(2), the health carrier or its designated utilization review organization shall provide to the selected independent review organization, the covered person, and the insurance department all information in its possession that is relevant to the adjudication of the matter in dispute, including: (1) The terms of agreement of the health benefit plan, including the evidence of coverage, benefit summary, or other similar document;(2) All relevant medical records, including records submitted to the carrier by the covered person, the covered person's authorized representative, or the covered person's treating provider;(3) A summary description of the applicable issues, including a statement of the health carrier's final determination;(4) The clinical review criteria used and the clinical reasons for the determination;(5) The relevant portions of the carrier's utilization management plan;(6) Any communications between the covered person and the health carrier regarding the internal or external review of the claim; and(7) All other documents, information, or criteria relied upon by the carrier in making its determination.(h) Failure by the health carrier or the covered person to provide the documents and information required in Ins 2703.05(g) or Ins 2703.05(d) (1) within the specified time frame shall not delay the conduct of the external review. If upon receipt of a notice from the insurance department the health carrier or its designee utilization review organization has failed to provide the documents and information within the time frame specified in paragraph (g), the commissioner shall terminate the external review and make a decision to reverse the adverse determination or final determination.(i) The selected independent review organization shall review all of the information and documents received from the carrier pursuant to Ins 2703.05(g) and any other information submitted by the covered person or the covered person's authorized representative or treating provider with the request for external review or pursuant to Ins 2703.05(d) (1) and any testimony provided.(j) The independent review organization may consider any applicable, generally accepted clinical practice guidelines, studies or research, including those developed or conducted by the federal government, national or professional medical societies, boards, and associations.(k) In conducting the review, the independent review organization shall review the correctness of all previously determined facts, allow the introduction of new information, and make a decision that is independent of the decisions or conclusions made by the health carrier during internal review.(l) The selected independent review organization shall render a decision upholding or reversing the determination of the health carrier and notify the covered person or the covered person's authorized representative, the health carrier, and the commissioner in writing within 20 days of the date that the record of the case is closed pursuant to Ins 2703.05(d) (1). This notice shall include a written review decision that contains a statement of the nature of the grievance, references to evidence or documentation considered in making the decision, findings of fact, and the clinical and legal rationale for the decision, including, as applicable, clinical review criteria and rulings of law, and a description of the qualifications of the reviewer or reviewers.(m) Upon receipt of a notice of a decision pursuant to Ins 2703.05(j) reversing the adverse determination or final adverse determination, the health carrier shall immediately approve the coverage that was the subject of the adverse determination or final adverse determination and provide confirmation of this to the insurance department. The confirmation provided to the insurance department shall include a statement of the amount of payment that was approved and the amount charged.(n) Upon receipt of the information required to be forwarded by the covered person or the commissioner to the health carrier pursuant to Ins 2703.05(d) (1) and (2) and prior to receipt of the decision of the selected independent review organization, the health carrier may reconsider the adverse determination or final adverse determination that is the subject of the external review. Reconsideration by the health carrier of its adverse determination or final adverse determination shall not delay or terminate the external review.(o) The external review shall only be terminated 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 health care service that is the subject of the adverse determination or final adverse determination.(p) Immediately upon making the decision to reverse its adverse determination or final adverse determination, as provided in Ins 2703.05(m), the health carrier shall notify the covered person, and if applicable, the covered person's authorized representative, the selected independent review organization, and the commissioner in writing of its decision and shall approve the coverage that was the subject of the adverse determination or final adverse determination. The selected independent review organization shall terminate the external review upon receipt of the notice from the health carrier and verification that coverage was approved.N.H. Admin. Code § Ins 2703.05
#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.