20-2535. Informal reconsideration
A. Any member who is denied a service and who does not qualify for an expedited
medical review pursuant to section 20-2534 may request, either orally or in writing, an
informal reconsideration of that denial by notifying the person described in section
20-2533, subsection C, paragraph 3. After the denial, the member has up to two years to
request an informal reconsideration. A health care insurer whose utilization review
consists only of claims review for services already provided is not required to provide
its members an informal reconsideration 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 informal reconsideration of a claim related to a
service already provided.
B. The utilization review agent shall mail a written acknowledgment to the member
and the member's treating provider within five business days after the utilization review
agent receives the request for informal reconsideration.
C. The utilization review agent may request any pertinent medical records pursuant
to title 12, chapter 13, article 7.1 that are necessary for the informal reconsideration.
D. The utilization review agent has up to thirty days after receipt of the request
for reconsideration to mail to the member and the member's treating provider a notice of
the utilization review agent's decision and the criteria used and the clinical reasons
for that decision.
E. At any time during the informal reconsideration process, the utilization review
agent may submit a request to the director to initiate an external independent review
process pursuant to section 20-2537. At the same time that the utilization review agent
submits the request to the director, the utilization review agent shall also render a
written decision and shall send the written decision, including the criteria used and the
clinical reasons for that decision and any references to supporting documentation, to the
member, the member's treating provider and the director.
F. If the utilization review agent does not submit a request to the director
pursuant to subsection E of this section and at the conclusion of the informal
reconsideration process the utilization review agent denies the covered service or the
claim for the covered service, the utilization review agent shall provide the member and
the treating provider with a written statement of the agent's decision and the criteria
used and the clinical reasons for that decision, including any references to any
supporting documentation and a notice of the option to proceed after the formal appeal
process to an external independent review.
G. If the utilization review agent concludes that the covered service should be
provided or the claim for a covered service should be paid, the health care insurer is
bound by the utilization review agent's decision.
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