Section Ins 2703.06 - Expedited External Review Expedited external review shall be conducted as follows:
(a) Expedited external review shall be available when the covered person's treating health care provider certifies to the department that adherence to the time frames specified in RSA 420-J:5-b would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function. A person who meets the standard for expedited external review may pursue expedited external review simultaneous with the internal review process in RSA 420-J:5, even without a final adverse determination.(b) Except to the extent that it is inconsistent with the provisions of this section, all requirements for the conduct of standard external review specified in Ins 2703.05 shall apply to expedited external review.(c) At the time the department receives a request for an expedited external review, the department shall immediately make a determination whether the request meets the standard set forth in Ins 2703.06(a) for expedited external review, as well as the reviewability requirements set forth in Ins 2703.05(a). If these conditions are met, the department shall immediately notify the health carrier. If the request is not complete, the department shall immediately contact the covered person or the covered person's authorized representative and attempt to obtain the information or documents that are needed to make the request complete.(d) If the commissioner determines that the covered person is eligible for external review on an expedited basis, the department shall select and retain an independent review organization that is certified pursuant to Ins 2703.07 to conduct the expedited external review.(e) The health carrier or its designated utilization review organization shall provide or transmit the documents and information specified in Ins 2703.05(g) to the selected independent review organization electronically or by telephone or facsimile or any other available expeditious method within one business day of receiving notification from the department of the request for expedited external review and of the commissioner's determination that the covered person is eligible for external review on an expedited basis.(f) When handling a review on an expedited basis, the selected independent review organization shall make a decision and notify the carrier and the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the expedited external review is requested by the commissioner's office.(g) If the notice provided pursuant to Ins 2703.06(f) was not in writing, within 2 business days after the date of providing that notice, the selected independent review organization shall: (1) Provide written confirmation of the decision to the covered person or the covered person's authorized representative and the health carrier; and(2) Include the information set forth in Ins 2703.05(j).(h) 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.(i) An expedited external review shall not be provided for determinations made by the health carrier on a retrospective basis.(j) If the expedited external review concerns a concurrent review determination, the service shall be continued pending the completion of the external review process. A covered person shall not be held liable to either the health plan, the hospital, the physician, or the services provider for the cost of services in excess of the applicable co-payment, coinsurance, or deductible incurred, pending the independent review organization's determination of an expedited external review.(k) When a covered person has requested expedited, second-level internal grievance review with a health carrier, the health carriers shall immediately notify the insurance department of the existence of the request and of the expected time frame for making a decision on that request.N.H. Admin. Code § Ins 2703.06
#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.