Section Ins 2703.09 - General Provisions Regarding External Review(a) The health carrier against which a request for external review is filed shall pay the cost of the external review. Except under the circumstances described below in this paragraph, such costs shall not exceed $1,500. The commissioner shall notify the independent review organizations of the cost limitation for conducting an external review. Costs in excess of $1,500 shall be allowed if the commissioner determines an additional cost is necessary to ensure the fair adjudication of the case in question.(b) The external review decision of the independent review organization shall be binding on the health carrier and shall be enforceable by the commissioner pursuant to the penalty provisions of RSA 420-J:14. The external review decision of the independent review organization shall be binding on the covered person except to the extent the covered person has other remedies available under federal or state law.(c) The external review process shall not be considered an adjudicative proceeding within the meaning of RSA 541-A, and the external review decision of the independent review organization shall not be subject to rehearing and appeal pursuant to RSA 541.(d) An independent review organization and the commissioner shall not disclose protected health information regarding covered persons that is collected in the external appeal process. In addition, the records and internal materials prepared for specific reviews by the commissioner and by an independent review organization under this section shall be exempt from public disclosure under RSA 91-A.(e) An independent review organization acting in good faith shall have immunity from any civil or criminal liability or professional discipline as a result of acts or omissions with respect to any external review, unless the acts or omissions constitute willful and wanton misconduct.(f) The right to external review under this chapter shall not be construed to change the terms of coverage under a health benefit plan nor shall the health carrier retaliate against the covered person for exercising his or her right to an independent external review.(g) When requested by the covered person, the commissioner shall provide consumer assistance in pursuing the internal grievance procedures under RSA 420-J:5 and the external review process under RSA 420-J:5-a - 420-J:5-e.(h) If, based on the evidence presented during the external review process, the commissioner determines that the health carrier's medical director, in the conduct of his or her duties, may have committed misconduct as set forth in RSA 329:17, VI, the commissioner shall document such findings and transmit them in a separate report to the board of medicine.N.H. Admin. Code § Ins 2703.09
#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.