§ 23-17.12-10 External appealrequirements. – (a) In cases where the second level of appeal to reverse an adversedetermination is unsuccessful, the review agent shall provide for an externalappeal by an unrelated and objective appeal agency, selected by the director.The director shall promulgate rules and regulations including, but not limitedto, criteria for designation, operation, policy, oversight, and termination ofdesignation as an external appeal agency. The external appeal agency shall notbe required to be certified under this chapter for activities conductedpursuant to its designation.
(b) The external appeal shall have the followingcharacteristics:
(1) The external appeal review and decision shall be based onthe medical necessity for the health care or service and the appropriateness ofservice delivery for which authorization has been denied.
(2) Neutral physicians, dentists, or other practitioners inthe same or similar general specialty as typically manages the health careservice shall be utilized to make the external appeal decisions.
(3) Neutral physicians, dentists, or other practitionersshall be selected from lists:
(i) Mutually agreed upon by the provider associations,insurers, and the purchasers of health services; and
(ii) Used during a twelve (12) month period as the source ofnames for neutral physician, dentist, or other practitioner reviewers.
(4) The neutral physician, dentist, or other practitioner mayconfer either directly with the review agent and provider, or with physiciansor dentists appointed to represent them.
(5) Payment for the appeal fee charged by the neutralphysician, dentist, or other practitioner shall be shared equally between thetwo (2) parties to the appeal; provided, however, that if the decision of theutilization review agent is overturned, the appealing party shall be reimbursedby the utilization review agent for their share of the appeal fee paid underthis subsection.
(6) The decision of the external appeal agency shall bebinding; however, any person who is aggrieved by a final decision of theexternal appeal agency is entitled to judicial review in a court of competentjurisdiction.
§ 23-17.12-10 External appealrequirements. – (a) In cases where the second level of appeal to reverse an adversedetermination is unsuccessful, the review agent shall provide for an externalappeal by an unrelated and objective appeal agency, selected by the director.The director shall promulgate rules and regulations including, but not limitedto, criteria for designation, operation, policy, oversight, and termination ofdesignation as an external appeal agency. The external appeal agency shall notbe required to be certified under this chapter for activities conductedpursuant to its designation.
(b) The external appeal shall have the followingcharacteristics:
(1) The external appeal review and decision shall be based onthe medical necessity for the health care or service and the appropriateness ofservice delivery for which authorization has been denied.
(2) Neutral physicians, dentists, or other practitioners inthe same or similar general specialty as typically manages the health careservice shall be utilized to make the external appeal decisions.
(3) Neutral physicians, dentists, or other practitionersshall be selected from lists:
(i) Mutually agreed upon by the provider associations,insurers, and the purchasers of health services; and
(ii) Used during a twelve (12) month period as the source ofnames for neutral physician, dentist, or other practitioner reviewers.
(4) The neutral physician, dentist, or other practitioner mayconfer either directly with the review agent and provider, or with physiciansor dentists appointed to represent them.
(5) Payment for the appeal fee charged by the neutralphysician, dentist, or other practitioner shall be shared equally between thetwo (2) parties to the appeal; provided, however, that if the decision of theutilization review agent is overturned, the appealing party shall be reimbursedby the utilization review agent for their share of the appeal fee paid underthis subsection.
(6) The decision of the external appeal agency shall bebinding; however, any person who is aggrieved by a final decision of theexternal appeal agency is entitled to judicial review in a court of competentjurisdiction.
§ 23-17.12-10 External appealrequirements. – (a) In cases where the second level of appeal to reverse an adversedetermination is unsuccessful, the review agent shall provide for an externalappeal by an unrelated and objective appeal agency, selected by the director.The director shall promulgate rules and regulations including, but not limitedto, criteria for designation, operation, policy, oversight, and termination ofdesignation as an external appeal agency. The external appeal agency shall notbe required to be certified under this chapter for activities conductedpursuant to its designation.
(b) The external appeal shall have the followingcharacteristics:
(1) The external appeal review and decision shall be based onthe medical necessity for the health care or service and the appropriateness ofservice delivery for which authorization has been denied.
(2) Neutral physicians, dentists, or other practitioners inthe same or similar general specialty as typically manages the health careservice shall be utilized to make the external appeal decisions.
(3) Neutral physicians, dentists, or other practitionersshall be selected from lists:
(i) Mutually agreed upon by the provider associations,insurers, and the purchasers of health services; and
(ii) Used during a twelve (12) month period as the source ofnames for neutral physician, dentist, or other practitioner reviewers.
(4) The neutral physician, dentist, or other practitioner mayconfer either directly with the review agent and provider, or with physiciansor dentists appointed to represent them.
(5) Payment for the appeal fee charged by the neutralphysician, dentist, or other practitioner shall be shared equally between thetwo (2) parties to the appeal; provided, however, that if the decision of theutilization review agent is overturned, the appealing party shall be reimbursedby the utilization review agent for their share of the appeal fee paid underthis subsection.
(6) The decision of the external appeal agency shall bebinding; however, any person who is aggrieved by a final decision of theexternal appeal agency is entitled to judicial review in a court of competentjurisdiction.
