20-2536

20-2536. Formal appeal

A. After any applicable informal reconsideration pursuant to section 20-2535, if
the utilization review agent denies the member's request for a covered service, the
member may appeal that adverse decision. The member shall mail a written appeal to the
utilization review agent within sixty days after receipt of the adverse decision. In the
event of a denial of a claim for a service that has already been provided, the member may
appeal that denial by filing a written appeal with the utilization review agent within
two years after receipt of the notice of the denial.

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 agent receives the
formal appeal.

C. The member or the member's treating provider shall submit to the utilization
review agent with the written formal appeal any material justification or documentation
to support the member's request for the service or claim for a service.

D. If the member's complaint is an issue of medical necessity under the coverage
document and not whether the service is covered, 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, 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 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 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.

E. Except as provided in subsection F of this section, the utilization review agent
has:

1. With respect to adverse decisions relating to services that have not been
provided, up to thirty days after receipt of the written appeal to notify the member in
writing of the utilization review agent's decision and the criteria used and the clinical
reasons for that decision.

2. With respect to denials relating to claims that have already been provided, up
to sixty days after receipt of the written appeal to notify the member in writing of the
utilization review agent's decision and the criteria used and the clinical reasons for
that decision.

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

G. If at the conclusion of the formal appeal process the utilization review agent
denies the appeal and the utilization review agent does not initiate the external
independent review process, the utilization review agent shall provide the member with
notice of the option to proceed to an external independent review pursuant to section
20-2537.

H. 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.