(a) Within 120 daysafter the date of receipt of a notice under G.S. 58‑50‑77, acovered person may file a request for an external review with the Commissioner.
(b) Upon receipt of arequest for an external review under subsection (a) of this section, theCommissioner shall, within 10 business days, complete all of the following:
(1) Notify and send acopy of the request to the insurer that made the decision which is the subjectof the request. The notice shall include a request for any information that theCommissioner requires to conduct the preliminary review under subdivision (2)of this subsection and require that the insurer deliver the requestedinformation to the Commissioner within three business days of receipt of thenotice.
(2) Conduct apreliminary review of the request to determine whether:
a. The individual is orwas a covered person in the health benefit plan at the time the health careservice was requested or, in the case of a retrospective review, was a coveredperson in the health benefit plan at the time the health care service wasprovided.
b. The health careservice that is the subject of the noncertification appeal decision or thesecond‑level grievance review decision upholding a noncertification reasonablyappears to be a covered service under the covered person's health benefit plan.
c. The covered personhas exhausted the insurer's internal appeal and grievance processes under G.S.58‑50‑61 and G.S. 58‑50‑62, unless the covered personis considered to have exhausted the insurer's internal appeal or grievanceprocess under G.S. 58‑50‑79, or unless the insurer has waived itsright to conduct an expedited review of the appeal decision.
d. The covered personhas provided all the information and forms required by the Commissioner thatare necessary to process an external review.
(3) Notify in writingthe covered person and the covered person's provider who performed or requestedthe service whether the request is complete and whether the request has beenaccepted for external review. If the request is complete and accepted forexternal review, the notice shall include a copy of the information that theinsurer provided to the Commissioner pursuant to subdivision (b)(1) of thissection, and inform the covered person that the covered person may submit tothe assigned independent review organization in writing, within seven daysafter the receipt of the notice, additional information and supportingdocumentation relevant to the initial denial for the organization to considerwhen conducting the external review. If the covered person chooses to sendadditional information to the assigned independent review organization, thenthe covered person shall at the same time and by the same means, send a copy ofthat information to the insurer. The Commissioner shall also notify the coveredperson in writing of the availability of assistance from the Managed CarePatient Assistance Program, including the telephone number and address of theProgram.
(4) Notify the insurerin writing whether the request for external review has been accepted. If therequest has been accepted, the notice shall direct the insurer or its designeeutilization review organization to provide to the assigned organization and tothe covered person or authorized representative who made the request forexternal review on behalf of the covered person, within seven days of receiptof the notice, the documents and any information considered in making thenoncertification appeal decision or the second‑level grievance reviewdecision.
(5) Assign the review toan independent review organization approved under G.S. 58‑50‑85.The assignment shall be made using an alphabetical list of the independentreview organizations, systematically assigning reviews on a rotating basis tothe next independent review organization on that list capable of performing thereview to conduct the external review. After the last organization on the listhas been assigned a review, the Commissioner shall return to the top of the listto continue assigning reviews.
(6) Forward to thereview organization that was assigned by the Commissioner any documents thatwere received relating to the request for external review.
(c) If the finding ofthe preliminary review under subdivision (b)(2) of this section is that therequest is not complete, the Commissioner shall request from the covered personthe information or materials needed to make the request complete. The coveredperson shall furnish the Commissioner with the requested information ormaterials within 150 days after the date of the insurer's decision for whichexternal review is requested.
(d) If the finding ofthe preliminary review under subdivision (b)(2) of this section is that therequest is not accepted for external review, the Commissioner shall inform thecovered person, the covered person's provider who performed or requested theservice, and the insurer in writing of the reasons for its nonacceptance.
(e) Failure by theinsurer or its designee utilization review organization to provide thedocuments and information within the time specified in this subsection shallnot delay the conduct of the external review. However, if the insurer or itsutilization review organization fails to provide the documents and informationwithin the time specified in subdivision (b)(4) of this section, the assignedorganization may terminate the external review and make a decision to reversethe noncertification appeal decision or the second‑level grievance reviewdecision. Within one business day of making the decision under this subsection,the organization shall notify the covered person, the insurer, and theCommissioner.
(f) If the coveredperson submits additional information to the Commissioner pursuant tosubdivision (b)(3) of this section, the Commissioner shall forward theinformation to the assigned review organization within two business days ofreceiving it and shall forward a copy of the information to the insurer.
(g) Upon receipt of theinformation required to be forwarded under subsection (f) of this section, theinsurer may reconsider its noncertification appeal decision or second‑levelgrievance review decision that is the subject of the external review.Reconsideration by the insurer of its noncertification appeal decision or second‑levelgrievance review decision under this subsection shall not delay or terminatethe external review. The external review shall be terminated if the insurerdecides, upon completion of its reconsideration, to reverse itsnoncertification appeal decision or second‑level grievance reviewdecision and provide coverage or payment for the requested health care servicethat is the subject of the noncertification appeal decision or second‑levelgrievance review decision.
(h) Upon making thedecision to reverse its noncertification appeal decision or second‑levelgrievance review decision under subsection (g) of this section, the insurershall notify the covered person, the organization, and the Commissioner inwriting of its decision. The organization shall terminate the external reviewupon receipt of the notice from the insurer sent under this subsection.
(i) The assignedorganization shall review all of the information and documents received undersubsections (b) and (f) of this section that have been forwarded to theorganization by the Commissioner and the insurer. In addition, the assignedreview organization, to the extent the documents or information are available,shall consider the following in reaching a decision:
(1) The covered person'smedical records.
(2) The attending healthcare provider's recommendation.
(3) Consulting reportsfrom appropriate health care providers and other documents submitted by theinsurer, covered person, or the covered person's treating provider.
(4) The most appropriatepractice guidelines that are based on sound clinical evidence and that areperiodically evaluated to assure ongoing efficacy.
(5) Any applicableclinical review criteria developed and used by the insurer or its designeeutilization review organization.
(6) Medical necessity,as defined in G.S. 58‑3‑200(b).
(7) Any documentationsupporting the medical necessity and appropriateness of the provider'srecommendation.
The assigned organizationshall review the terms of coverage under the covered person's health benefitplan to ensure that the organization's decision shall not be contrary to theterms of coverage under the covered person's health benefit plan with theinsurer.
The assigned organization'sdetermination shall be based on the covered person's medical condition at thetime of the initial noncertification decision.
(j) Within 45 daysafter the date of receipt by the Commissioner of the request for externalreview, the assigned organization shall provide written notice of its decisionto uphold or reverse the noncertification appeal decision or second‑levelgrievance review decision to the covered person, the insurer, the coveredperson's provider who performed or requested the service, and the Commissioner.In reaching a decision, the assigned review organization is not bound by anydecisions or conclusions reached during the insurer's utilization reviewprocess or the insurer's internal grievance process under G.S. 58‑50‑61and G.S. 58‑50‑62.
(k) The organizationshall include in the notice sent under subsection (j) of this section:
(1) A generaldescription of the reason for the request for external review.
(2) The date theorganization received the assignment from the Commissioner to conduct theexternal review.
(3) The date theorganization received information and documents submitted by the covered personand by the insurer.
(4) The date theexternal review was conducted.
(5) The date of itsdecision.
(6) The principal reasonor reasons for its decision.
(7) The clinicalrationale for its decision.
(8) References to theevidence or documentation, including the practice guidelines, considered inreaching its decision.
(9) The professionalqualifications and licensure of the clinical peer reviewers.
(10) Notice to the coveredperson that he or she is not liable for the cost of the external review.
(l) Upon receipt of anotice of a decision under subsection (k) of this section reversing thenoncertification appeal decision or second‑level grievance reviewdecision, the insurer shall within three business days reverse thenoncertification appeal decision or second‑level grievance reviewdecision that was the subject of the review and shall provide coverage orpayment for the requested health care service or supply that was the subject ofthe noncertification appeal decision or second‑level grievance reviewdecision. In the event the covered person is no longer enrolled in the healthbenefit plan when the insurer receives notice of a decision under subsection(k) of this section reversing the noncertification appeal decision or second‑levelgrievance review decision, the insurer that made the noncertification appealdecision or second‑level grievance review decision shall be responsibleunder this section only for the costs of those services or supplies the coveredperson received or would have received prior to disenrollment if the servicehad not been denied when first requested.
(m) For the purposes ofthis section, a person is presumed to have received a written notice two daysafter the notice has been placed, first‑class postage prepaid, in theUnited States mail addressed to the person. The presumption may be rebutted bysufficient evidence that the notice was received on another day or not receivedat all. (2001‑446,s. 4.5; 2002‑187, ss. 3.1, 3.2; 2003‑105, s. 3; 2005‑223, s.10(a); 2009‑382, ss. 26, 27.)
(a) Within 120 daysafter the date of receipt of a notice under G.S. 58‑50‑77, acovered person may file a request for an external review with the Commissioner.
(b) Upon receipt of arequest for an external review under subsection (a) of this section, theCommissioner shall, within 10 business days, complete all of the following:
(1) Notify and send acopy of the request to the insurer that made the decision which is the subjectof the request. The notice shall include a request for any information that theCommissioner requires to conduct the preliminary review under subdivision (2)of this subsection and require that the insurer deliver the requestedinformation to the Commissioner within three business days of receipt of thenotice.
(2) Conduct apreliminary review of the request to determine whether:
a. The individual is orwas a covered person in the health benefit plan at the time the health careservice was requested or, in the case of a retrospective review, was a coveredperson in the health benefit plan at the time the health care service wasprovided.
b. The health careservice that is the subject of the noncertification appeal decision or thesecond‑level grievance review decision upholding a noncertification reasonablyappears to be a covered service under the covered person's health benefit plan.
c. The covered personhas exhausted the insurer's internal appeal and grievance processes under G.S.58‑50‑61 and G.S. 58‑50‑62, unless the covered personis considered to have exhausted the insurer's internal appeal or grievanceprocess under G.S. 58‑50‑79, or unless the insurer has waived itsright to conduct an expedited review of the appeal decision.
d. The covered personhas provided all the information and forms required by the Commissioner thatare necessary to process an external review.
(3) Notify in writingthe covered person and the covered person's provider who performed or requestedthe service whether the request is complete and whether the request has beenaccepted for external review. If the request is complete and accepted forexternal review, the notice shall include a copy of the information that theinsurer provided to the Commissioner pursuant to subdivision (b)(1) of thissection, and inform the covered person that the covered person may submit tothe assigned independent review organization in writing, within seven daysafter the receipt of the notice, additional information and supportingdocumentation relevant to the initial denial for the organization to considerwhen conducting the external review. If the covered person chooses to sendadditional information to the assigned independent review organization, thenthe covered person shall at the same time and by the same means, send a copy ofthat information to the insurer. The Commissioner shall also notify the coveredperson in writing of the availability of assistance from the Managed CarePatient Assistance Program, including the telephone number and address of theProgram.
(4) Notify the insurerin writing whether the request for external review has been accepted. If therequest has been accepted, the notice shall direct the insurer or its designeeutilization review organization to provide to the assigned organization and tothe covered person or authorized representative who made the request forexternal review on behalf of the covered person, within seven days of receiptof the notice, the documents and any information considered in making thenoncertification appeal decision or the second‑level grievance reviewdecision.
(5) Assign the review toan independent review organization approved under G.S. 58‑50‑85.The assignment shall be made using an alphabetical list of the independentreview organizations, systematically assigning reviews on a rotating basis tothe next independent review organization on that list capable of performing thereview to conduct the external review. After the last organization on the listhas been assigned a review, the Commissioner shall return to the top of the listto continue assigning reviews.
(6) Forward to thereview organization that was assigned by the Commissioner any documents thatwere received relating to the request for external review.
(c) If the finding ofthe preliminary review under subdivision (b)(2) of this section is that therequest is not complete, the Commissioner shall request from the covered personthe information or materials needed to make the request complete. The coveredperson shall furnish the Commissioner with the requested information ormaterials within 150 days after the date of the insurer's decision for whichexternal review is requested.
(d) If the finding ofthe preliminary review under subdivision (b)(2) of this section is that therequest is not accepted for external review, the Commissioner shall inform thecovered person, the covered person's provider who performed or requested theservice, and the insurer in writing of the reasons for its nonacceptance.
(e) Failure by theinsurer or its designee utilization review organization to provide thedocuments and information within the time specified in this subsection shallnot delay the conduct of the external review. However, if the insurer or itsutilization review organization fails to provide the documents and informationwithin the time specified in subdivision (b)(4) of this section, the assignedorganization may terminate the external review and make a decision to reversethe noncertification appeal decision or the second‑level grievance reviewdecision. Within one business day of making the decision under this subsection,the organization shall notify the covered person, the insurer, and theCommissioner.
(f) If the coveredperson submits additional information to the Commissioner pursuant tosubdivision (b)(3) of this section, the Commissioner shall forward theinformation to the assigned review organization within two business days ofreceiving it and shall forward a copy of the information to the insurer.
(g) Upon receipt of theinformation required to be forwarded under subsection (f) of this section, theinsurer may reconsider its noncertification appeal decision or second‑levelgrievance review decision that is the subject of the external review.Reconsideration by the insurer of its noncertification appeal decision or second‑levelgrievance review decision under this subsection shall not delay or terminatethe external review. The external review shall be terminated if the insurerdecides, upon completion of its reconsideration, to reverse itsnoncertification appeal decision or second‑level grievance reviewdecision and provide coverage or payment for the requested health care servicethat is the subject of the noncertification appeal decision or second‑levelgrievance review decision.
(h) Upon making thedecision to reverse its noncertification appeal decision or second‑levelgrievance review decision under subsection (g) of this section, the insurershall notify the covered person, the organization, and the Commissioner inwriting of its decision. The organization shall terminate the external reviewupon receipt of the notice from the insurer sent under this subsection.
(i) The assignedorganization shall review all of the information and documents received undersubsections (b) and (f) of this section that have been forwarded to theorganization by the Commissioner and the insurer. In addition, the assignedreview organization, to the extent the documents or information are available,shall consider the following in reaching a decision:
(1) The covered person'smedical records.
(2) The attending healthcare provider's recommendation.
(3) Consulting reportsfrom appropriate health care providers and other documents submitted by theinsurer, covered person, or the covered person's treating provider.
(4) The most appropriatepractice guidelines that are based on sound clinical evidence and that areperiodically evaluated to assure ongoing efficacy.
(5) Any applicableclinical review criteria developed and used by the insurer or its designeeutilization review organization.
(6) Medical necessity,as defined in G.S. 58‑3‑200(b).
(7) Any documentationsupporting the medical necessity and appropriateness of the provider'srecommendation.
The assigned organizationshall review the terms of coverage under the covered person's health benefitplan to ensure that the organization's decision shall not be contrary to theterms of coverage under the covered person's health benefit plan with theinsurer.
The assigned organization'sdetermination shall be based on the covered person's medical condition at thetime of the initial noncertification decision.
(j) Within 45 daysafter the date of receipt by the Commissioner of the request for externalreview, the assigned organization shall provide written notice of its decisionto uphold or reverse the noncertification appeal decision or second‑levelgrievance review decision to the covered person, the insurer, the coveredperson's provider who performed or requested the service, and the Commissioner.In reaching a decision, the assigned review organization is not bound by anydecisions or conclusions reached during the insurer's utilization reviewprocess or the insurer's internal grievance process under G.S. 58‑50‑61and G.S. 58‑50‑62.
(k) The organizationshall include in the notice sent under subsection (j) of this section:
(1) A generaldescription of the reason for the request for external review.
(2) The date theorganization received the assignment from the Commissioner to conduct theexternal review.
(3) The date theorganization received information and documents submitted by the covered personand by the insurer.
(4) The date theexternal review was conducted.
(5) The date of itsdecision.
(6) The principal reasonor reasons for its decision.
(7) The clinicalrationale for its decision.
(8) References to theevidence or documentation, including the practice guidelines, considered inreaching its decision.
(9) The professionalqualifications and licensure of the clinical peer reviewers.
(10) Notice to the coveredperson that he or she is not liable for the cost of the external review.
(l) Upon receipt of anotice of a decision under subsection (k) of this section reversing thenoncertification appeal decision or second‑level grievance reviewdecision, the insurer shall within three business days reverse thenoncertification appeal decision or second‑level grievance reviewdecision that was the subject of the review and shall provide coverage orpayment for the requested health care service or supply that was the subject ofthe noncertification appeal decision or second‑level grievance reviewdecision. In the event the covered person is no longer enrolled in the healthbenefit plan when the insurer receives notice of a decision under subsection(k) of this section reversing the noncertification appeal decision or second‑levelgrievance review decision, the insurer that made the noncertification appealdecision or second‑level grievance review decision shall be responsibleunder this section only for the costs of those services or supplies the coveredperson received or would have received prior to disenrollment if the servicehad not been denied when first requested.
(m) For the purposes ofthis section, a person is presumed to have received a written notice two daysafter the notice has been placed, first‑class postage prepaid, in theUnited States mail addressed to the person. The presumption may be rebutted bysufficient evidence that the notice was received on another day or not receivedat all. (2001‑446,s. 4.5; 2002‑187, ss. 3.1, 3.2; 2003‑105, s. 3; 2005‑223, s.10(a); 2009‑382, ss. 26, 27.)
(a) Within 120 daysafter the date of receipt of a notice under G.S. 58‑50‑77, acovered person may file a request for an external review with the Commissioner.
(b) Upon receipt of arequest for an external review under subsection (a) of this section, theCommissioner shall, within 10 business days, complete all of the following:
(1) Notify and send acopy of the request to the insurer that made the decision which is the subjectof the request. The notice shall include a request for any information that theCommissioner requires to conduct the preliminary review under subdivision (2)of this subsection and require that the insurer deliver the requestedinformation to the Commissioner within three business days of receipt of thenotice.
(2) Conduct apreliminary review of the request to determine whether:
a. The individual is orwas a covered person in the health benefit plan at the time the health careservice was requested or, in the case of a retrospective review, was a coveredperson in the health benefit plan at the time the health care service wasprovided.
b. The health careservice that is the subject of the noncertification appeal decision or thesecond‑level grievance review decision upholding a noncertification reasonablyappears to be a covered service under the covered person's health benefit plan.
c. The covered personhas exhausted the insurer's internal appeal and grievance processes under G.S.58‑50‑61 and G.S. 58‑50‑62, unless the covered personis considered to have exhausted the insurer's internal appeal or grievanceprocess under G.S. 58‑50‑79, or unless the insurer has waived itsright to conduct an expedited review of the appeal decision.
d. The covered personhas provided all the information and forms required by the Commissioner thatare necessary to process an external review.
(3) Notify in writingthe covered person and the covered person's provider who performed or requestedthe service whether the request is complete and whether the request has beenaccepted for external review. If the request is complete and accepted forexternal review, the notice shall include a copy of the information that theinsurer provided to the Commissioner pursuant to subdivision (b)(1) of thissection, and inform the covered person that the covered person may submit tothe assigned independent review organization in writing, within seven daysafter the receipt of the notice, additional information and supportingdocumentation relevant to the initial denial for the organization to considerwhen conducting the external review. If the covered person chooses to sendadditional information to the assigned independent review organization, thenthe covered person shall at the same time and by the same means, send a copy ofthat information to the insurer. The Commissioner shall also notify the coveredperson in writing of the availability of assistance from the Managed CarePatient Assistance Program, including the telephone number and address of theProgram.
(4) Notify the insurerin writing whether the request for external review has been accepted. If therequest has been accepted, the notice shall direct the insurer or its designeeutilization review organization to provide to the assigned organization and tothe covered person or authorized representative who made the request forexternal review on behalf of the covered person, within seven days of receiptof the notice, the documents and any information considered in making thenoncertification appeal decision or the second‑level grievance reviewdecision.
(5) Assign the review toan independent review organization approved under G.S. 58‑50‑85.The assignment shall be made using an alphabetical list of the independentreview organizations, systematically assigning reviews on a rotating basis tothe next independent review organization on that list capable of performing thereview to conduct the external review. After the last organization on the listhas been assigned a review, the Commissioner shall return to the top of the listto continue assigning reviews.
(6) Forward to thereview organization that was assigned by the Commissioner any documents thatwere received relating to the request for external review.
(c) If the finding ofthe preliminary review under subdivision (b)(2) of this section is that therequest is not complete, the Commissioner shall request from the covered personthe information or materials needed to make the request complete. The coveredperson shall furnish the Commissioner with the requested information ormaterials within 150 days after the date of the insurer's decision for whichexternal review is requested.
(d) If the finding ofthe preliminary review under subdivision (b)(2) of this section is that therequest is not accepted for external review, the Commissioner shall inform thecovered person, the covered person's provider who performed or requested theservice, and the insurer in writing of the reasons for its nonacceptance.
(e) Failure by theinsurer or its designee utilization review organization to provide thedocuments and information within the time specified in this subsection shallnot delay the conduct of the external review. However, if the insurer or itsutilization review organization fails to provide the documents and informationwithin the time specified in subdivision (b)(4) of this section, the assignedorganization may terminate the external review and make a decision to reversethe noncertification appeal decision or the second‑level grievance reviewdecision. Within one business day of making the decision under this subsection,the organization shall notify the covered person, the insurer, and theCommissioner.
(f) If the coveredperson submits additional information to the Commissioner pursuant tosubdivision (b)(3) of this section, the Commissioner shall forward theinformation to the assigned review organization within two business days ofreceiving it and shall forward a copy of the information to the insurer.
(g) Upon receipt of theinformation required to be forwarded under subsection (f) of this section, theinsurer may reconsider its noncertification appeal decision or second‑levelgrievance review decision that is the subject of the external review.Reconsideration by the insurer of its noncertification appeal decision or second‑levelgrievance review decision under this subsection shall not delay or terminatethe external review. The external review shall be terminated if the insurerdecides, upon completion of its reconsideration, to reverse itsnoncertification appeal decision or second‑level grievance reviewdecision and provide coverage or payment for the requested health care servicethat is the subject of the noncertification appeal decision or second‑levelgrievance review decision.
(h) Upon making thedecision to reverse its noncertification appeal decision or second‑levelgrievance review decision under subsection (g) of this section, the insurershall notify the covered person, the organization, and the Commissioner inwriting of its decision. The organization shall terminate the external reviewupon receipt of the notice from the insurer sent under this subsection.
(i) The assignedorganization shall review all of the information and documents received undersubsections (b) and (f) of this section that have been forwarded to theorganization by the Commissioner and the insurer. In addition, the assignedreview organization, to the extent the documents or information are available,shall consider the following in reaching a decision:
(1) The covered person'smedical records.
(2) The attending healthcare provider's recommendation.
(3) Consulting reportsfrom appropriate health care providers and other documents submitted by theinsurer, covered person, or the covered person's treating provider.
(4) The most appropriatepractice guidelines that are based on sound clinical evidence and that areperiodically evaluated to assure ongoing efficacy.
(5) Any applicableclinical review criteria developed and used by the insurer or its designeeutilization review organization.
(6) Medical necessity,as defined in G.S. 58‑3‑200(b).
(7) Any documentationsupporting the medical necessity and appropriateness of the provider'srecommendation.
The assigned organizationshall review the terms of coverage under the covered person's health benefitplan to ensure that the organization's decision shall not be contrary to theterms of coverage under the covered person's health benefit plan with theinsurer.
The assigned organization'sdetermination shall be based on the covered person's medical condition at thetime of the initial noncertification decision.
(j) Within 45 daysafter the date of receipt by the Commissioner of the request for externalreview, the assigned organization shall provide written notice of its decisionto uphold or reverse the noncertification appeal decision or second‑levelgrievance review decision to the covered person, the insurer, the coveredperson's provider who performed or requested the service, and the Commissioner.In reaching a decision, the assigned review organization is not bound by anydecisions or conclusions reached during the insurer's utilization reviewprocess or the insurer's internal grievance process under G.S. 58‑50‑61and G.S. 58‑50‑62.
(k) The organizationshall include in the notice sent under subsection (j) of this section:
(1) A generaldescription of the reason for the request for external review.
(2) The date theorganization received the assignment from the Commissioner to conduct theexternal review.
(3) The date theorganization received information and documents submitted by the covered personand by the insurer.
(4) The date theexternal review was conducted.
(5) The date of itsdecision.
(6) The principal reasonor reasons for its decision.
(7) The clinicalrationale for its decision.
(8) References to theevidence or documentation, including the practice guidelines, considered inreaching its decision.
(9) The professionalqualifications and licensure of the clinical peer reviewers.
(10) Notice to the coveredperson that he or she is not liable for the cost of the external review.
(l) Upon receipt of anotice of a decision under subsection (k) of this section reversing thenoncertification appeal decision or second‑level grievance reviewdecision, the insurer shall within three business days reverse thenoncertification appeal decision or second‑level grievance reviewdecision that was the subject of the review and shall provide coverage orpayment for the requested health care service or supply that was the subject ofthe noncertification appeal decision or second‑level grievance reviewdecision. In the event the covered person is no longer enrolled in the healthbenefit plan when the insurer receives notice of a decision under subsection(k) of this section reversing the noncertification appeal decision or second‑levelgrievance review decision, the insurer that made the noncertification appealdecision or second‑level grievance review decision shall be responsibleunder this section only for the costs of those services or supplies the coveredperson received or would have received prior to disenrollment if the servicehad not been denied when first requested.
(m) For the purposes ofthis section, a person is presumed to have received a written notice two daysafter the notice has been placed, first‑class postage prepaid, in theUnited States mail addressed to the person. The presumption may be rebutted bysufficient evidence that the notice was received on another day or not receivedat all. (2001‑446,s. 4.5; 2002‑187, ss. 3.1, 3.2; 2003‑105, s. 3; 2005‑223, s.10(a); 2009‑382, ss. 26, 27.)
