Section 17B:30-55.12 - [Effective 1/1/2025] Adverse determinations, appeal, reviewed by physicianA payer shall ensure that any adverse determinations of any appeal are reviewed by a physician. The physician shall:
a. be board-certified in a same or similar specialty that has experience treating the condition or service under review or has experience treating the condition within the last five years;b. not be paid by a payer based on the reviewing physician's denial or approval rate;c. not have been directly involved in making an initial adverse determination for the same claim;d. consider all known clinical aspects of the health care service under review, including, but not limited to, a review of all pertinent medical records provided to the payer by the health care provider of the covered person, any relevant records provided to the payer by a health care facility, and any medical literature provided to the payer by the health care service provider of the covered person;e. not be provided preferential treatment by the payer in the reviewing physician's own requests for prior authorization if the reviewing physician is also a network provider; andf. when requested by the treating provider, engage in a telephonic conversation with the treating provider to discuss the need for the prescribed medication or service.Added by L. 2023 , c. 296, s. 13, eff. 1/1/2025.