§432E-6.5  Expedited appeal, when
authorized; standard for decision.  (a)  An enrollee may request that the
following be conducted as an expedited appeal:



(1)  The internal review under section 432E-5 of the
enrollee's complaint; or



(2)  The external review under section 432E-6 of the
managed care plan's final internal determination.



If a request for expedited appeal is approved by the
managed care plan or the commissioner, the appropriate review shall be
completed within seventy-two hours of receipt of the request for expedited
appeal.



(b)  An expedited appeal shall be authorized if
the application of the sixty day standard review time frame may:



(1)  Seriously jeopardize the life or health of the
enrollee;



(2)  Seriously jeopardize the enrollee's ability to
gain maximum functioning; or



(3)  Subject the enrollee to severe pain that cannot
be adequately managed without the care or treatment that is the subject of the
expedited appeal.



(c)  The decision as to whether an enrollee's
complaint is an expedited appeal shall be made by applying the standard of a
reasonable individual who is not a trained health professional.  The decision
may be made for the managed care plan by an individual acting on behalf of the
managed care plan.  If a licensed health care provider with knowledge of a
claimant's medical condition requests an expedited appeal on behalf of an
enrollee, the request shall be treated as an expedited appeal. [L 2000, c 250,
§2; am L 2004, c 27, §2]