§1130. Appeals of adverse determinations; standard appeals
A. An MNRO shall establish written procedures for a standard appeal of an adverse determination, which may also be known as a first level internal appeal. Such procedures shall be available to the covered person and to the provider acting on behalf of the covered person. Such procedures shall provide for an appropriate review panel for each appeal that includes health care professionals who have appropriate expertise.
B. For standard appeals, a duly licensed physician shall be required to concur with any adverse determination made by the review panel.
C. The MNRO shall notify in writing both the covered person and the attending or ordering provider of the decision within thirty working days following the request for an appeal, unless the covered person or authorized representative and the MNRO mutually agree that a further extension of the time limit would be in the best interest of the covered person. The written decision shall contain the following:
(1) The title and qualifying credentials of the physician affirming the adverse determination.
(2) A statement of the reason for the covered person's request for an appeal.
(3) An explanation of the reviewers' decision in clear terms and the medical rationale in sufficient detail for the covered person to respond further to the MNRO's position.
(4) If applicable, a statement including the following:
(a) A description of the process to obtain a second level review of a decision.
(b) The written procedures governing a second level review, including any required time frame for review.
§1130. Appeals of adverse determinations; standard appeals
A. An MNRO shall establish written procedures for a standard appeal of an adverse determination, which may also be known as a first level internal appeal. Such procedures shall be available to the covered person and to the provider acting on behalf of the covered person. Such procedures shall provide for an appropriate review panel for each appeal that includes health care professionals who have appropriate expertise.
B. For standard appeals, a duly licensed physician shall be required to concur with any adverse determination made by the review panel.
C. The MNRO shall notify in writing both the covered person and the attending or ordering provider of the decision within thirty working days following the request for an appeal, unless the covered person or authorized representative and the MNRO mutually agree that a further extension of the time limit would be in the best interest of the covered person. The written decision shall contain the following:
(1) The title and qualifying credentials of the physician affirming the adverse determination.
(2) A statement of the reason for the covered person's request for an appeal.
(3) An explanation of the reviewers' decision in clear terms and the medical rationale in sufficient detail for the covered person to respond further to the MNRO's position.
(4) If applicable, a statement including the following:
(a) A description of the process to obtain a second level review of a decision.
(b) The written procedures governing a second level review, including any required time frame for review.
§1130. Appeals of adverse determinations; standard appeals
A. An MNRO shall establish written procedures for a standard appeal of an adverse determination, which may also be known as a first level internal appeal. Such procedures shall be available to the covered person and to the provider acting on behalf of the covered person. Such procedures shall provide for an appropriate review panel for each appeal that includes health care professionals who have appropriate expertise.
B. For standard appeals, a duly licensed physician shall be required to concur with any adverse determination made by the review panel.
C. The MNRO shall notify in writing both the covered person and the attending or ordering provider of the decision within thirty working days following the request for an appeal, unless the covered person or authorized representative and the MNRO mutually agree that a further extension of the time limit would be in the best interest of the covered person. The written decision shall contain the following:
(1) The title and qualifying credentials of the physician affirming the adverse determination.
(2) A statement of the reason for the covered person's request for an appeal.
(3) An explanation of the reviewers' decision in clear terms and the medical rationale in sufficient detail for the covered person to respond further to the MNRO's position.
(4) If applicable, a statement including the following:
(a) A description of the process to obtain a second level review of a decision.
(b) The written procedures governing a second level review, including any required time frame for review.
