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

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

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

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

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

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

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

(3)  Subject the enrollee to severe pain that cannotbe adequately managed without the care or treatment that is the subject of theexpedited appeal.

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