20-2534

20-2534. Expedited medical review; expedited
appeal

A. Any member who is denied a request for a covered service may pursue an expedited
medical review of that denial if the member's treating provider certifies in writing and
provides supporting documentation to the utilization review agent that the time period
for the informal reconsideration process and formal appeal process prescribed in sections
20-2535 and 20-2536 is likely to cause a significant negative change in the member's
medical condition at issue that is subject to the appeal. The treating provider's
certification is not challengeable by the health care insurer. A health care insurer
whose utilization review activities consist only of claims review for services already
provided is not required to provide its members an expedited medical review or expedited
appeal pursuant to this section. A health care insurer who conducts utilization review of
claims in connection with services already provided is not required to provide its
members an expedited medical review or expedited appeal of a claim related to a service
already provided.

B. On receipt of the certification and supporting documentation, the utilization
review agent has one business day to make a decision and mail to the member and the
member's treating provider a notice of that decision, including the criteria used and the
clinical reasons for that decision and any references to supporting documentation. If the
member's complaint is an issue of medical necessity under the coverage document and not
whether the service is covered, before making a decision, the agent shall consult with a
physician or other health care professional who is licensed pursuant to title 32, chapter
7, 8, 11, 13, 14, 17, 19 or 29 or an out of state provider, physician or other health
care professional who is licensed in another state and who is not licensed in this state
and who typically manages the medical condition under review.

C. If the utilization review agent affirms the denial of the requested service, the
agent shall telephonically provide and mail to the member and the member's treating
provider a notice of the adverse decision and of the member's option to immediately
proceed to an expedited appeal pursuant to subsection E of this section.

D. At any time during the expedited appeal process, the utilization review agent
may request an expedited external independent review process pursuant to section 20-2537.
If the utilization review agent initiates the expedited external independent review
process, the utilization review agent does not have to comply with subsection E of this
section.

E. If the member chooses to proceed with an expedited appeal, the member's treating
provider shall immediately submit a written appeal of the denial of the service to the
utilization review agent and provide the utilization review agent with any additional
material justification or documentation to support the member's request for the service.
Within three business days after receiving the request for an expedited appeal, the
utilization review agent shall provide notice of the expedited appeal decision as
prescribed in this subsection. If the member's complaint is an issue of medical necessity
under the coverage document and not whether the service is covered, any provider,
physician or other health care professional who is licensed pursuant to title 32, chapter
7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an out of state provider, physician or other
health care professional who is licensed in another state and who is not licensed in this
state, who is employed or under contract with the utilization review agent and who is
qualified in a similar scope of practice as a provider, physician or other health care
professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19,
19.1 or 29 or an out of state provider, physician or other health care professional who
is licensed in another state and who is not licensed in this state and who typically
manages the medical condition under appeal shall review the expedited appeal and render a
decision based on the utilization review plan adopted by the utilization review agent.
Pursuant to the requirements of this subsection, the utilization review agent shall
select the provider, physician or other health care professional who shall review the
appeal and render the decision. If the utilization review agent, provider, physician or
other health care professional denies the expedited appeal, the utilization review agent
shall telephonically provide and mail to the member and the member's treating provider a
notice of the denial and of the member's option to immediately proceed to the external
independent review prescribed in section 20-2537.

F. If the utilization review agent, provider, physician or other health care
professional concludes that the covered service should be provided, the health care
insurer is bound by the utilization review agent's decision.