June 22, 1999

No. 41

HB 64, relative to changes of registration for undeclared voters.

HB 112-FN-A, increasing the tobacco tax and imposing the tax on all types of tobacco products.

HB 294, relative to state aid to municipalities for closure of certain municipal incinerators.

HB 295, relative to alternative kindergarten programs in cooperative school districts.

HB 375, relative to substitutions for disqualified and deceased candidates.

HB 448, relative to the board of dental examiners and the regulation of dentists and dental hygienists.

HJR 1, requesting that the federal government prohibit the U.S. Fish and Wildlife Service or other federal agency from introducing wolf populations to the northeastern United States, especially New Hampshire.

Ought to Pass, Senator Krueger for the committee.

HB 369, establishing a committee on educational programs on tobacco use for minors. Vote 5-0

Ought to pass with amendment, Senator Wheeler for the committee.

HB 408, relative to drug formularies under managed care entities. Vote 4-0

Ought to pass with amendment, Senator Wheeler for the committee.

HB 486-FN-A, relative to the physician effectiveness program. Vote 4-0

Ought to Pass, Senator Squires for the committee.

HB 545-FN, establishing a committee to study ambulatory surgical facilities. Vote 5-0

Ought to Pass, Senator Squires for the committee.

HB 640, relative to grievance procedures of managed care organizations.

MINORITY REPORT: Ought to Pass, Senator Krueger for the committee. Vote 2-4

MAJORITY REPORT: Ought to pass with amendment, Senator Wheeler for the committee. Vote 4-2

HB 650-FN-A, establishing a committee to study the structure of alcohol and drug abuse prevention services. Vote 4-0

HB 657, relative to the health services planning and review board and the certificate of need process. Vote 5-0

Inexpedient to Legislate, Senator Squires for the committee.

HB 720-FN, relative to the practice of midwifery. Vote 5-0

Ought to Pass, Senator Squires for the committee.

Public Institutions, Health and Human Services

June 21, 1999

1999-1732s

01/09

Amend subparagraph I(b) as inserted by section 2 of the bill by replacing it with the following:

(b) Four members of the senate, one from the senate public affairs committee, one from the senate judiciary committee, one from the senate education committee, and one from the senate public institutions, health and human services committee, appointed by the president of the senate.

Public Institutions, Health and Human Services

June 21, 1999

1999-1735s

01/09

Amend RSA 420-J:7-b, III as inserted by section 1 of the bill by replacing it with the following:

III. Every health plan that provides prescription drug benefits shall notify covered persons of changes to the plan list or plan formulary, provide an explanation of the exception process by which a covered person can access nonformulary medically necessary prescription drugs, and provide a toll-free telephone number through which a covered person can request additional information. Upon notification to covered persons, the health benefit plan shall allow at least 45 days before implementation of any formulary change; provided, however, that advance notice shall not be required if the federal food and drug administration has determined that a prescription drug on the health benefit plan's formulary is unsafe.

Public Institutions, Health and Human Services

June 21, 1999

1999-1730s

01/09

Amend the title of the bill by replacing it with the following:

AN ACT establishing certain standards of accountability for health maintenance organizations and other entities providing health insurance through a managed care system.

Amend the bill by replacing all after the enacting clause with the following:

1 Statement of Purpose. The purpose and intent of this act is to strengthen protections for New Hampshire families who receive their medical care from managed care organizations by providing consumers with the information and tools consumers need to hold managed care organizations accountable for the health care treatment decisions they make.

2 Practice of Medicine; Medical Directors. Amend RSA 329:1 to read as follows:

329:1 Practice. Any person shall be regarded as practicing medicine under the meaning of this chapter who shall diagnose, treat, perform surgery, or prescribe any treatment of medicine for any disease or human ailment. "Surgery" means any procedure, including but not limited to laser, in which human tissue is cut, shaped, burned, vaporized, or otherwise structurally altered, except that this section shall not apply to any person to whom authority is given by any other statute to perform acts which might otherwise be deemed the practice of medicine. "Laser" means light amplification by stimulated emission of radiation. A medical director, as defined in RSA 420-J:3, XXV-a, shall be regarded as practicing medicine under the meaning of this chapter whenever: I. A medical necessity determination is made for which he or she is responsible under RSA 420-J:6, V or RSA 420-E:2-a; II. The medical necessity determination denies authorization or payment for a covered health care service, supply or drug that the treating health care provider has prescribed; and III. Such denial causes the covered person not to receive the health care service, supply or drug that the treating health care provider has prescribed. 3 New Section; Medical Directors Required. Amend RSA 420-E by inserting after section 2 the following new section:

420-E:2-a Medical Director. Every medical utilization review entity licensed by the department under this chapter shall employ a medical director licensed under RSA 329, who shall have final responsibility for the utilization system and its administration and implementation, including utilization review decisions affecting health care services provided to beneficiaries.

4 New Paragraph; Definition Added. Amend RSA 420-J:3 by inserting after paragraph XXV the following new paragraph:

XXV-a. "Medical director" means a physician licensed under RSA 329 and employed by a health carrier or medical utilization review entity who is responsible for the utilization review techniques and methods of the health carrier or medical utilization review entity and their administration and implementation, including utilization review decisions affecting health care services provided to covered persons under a health benefit plan.

5 New Paragraph; Medical Director Required. Amend RSA 420-J:6 by inserting after paragraph IV the following new paragraph:

V. Each health carrier that conducts utilization review shall employ a medical director who shall have final responsibility for all utilization review techniques and methods and their administration and implementation, including utilization review decisions affecting health care services provided to covered persons under a health benefit plan.

6 Information Provided to Covered Persons. Amend RSA 420-J:5, II to read as follows:

II. A health carrier shall provide to consumers:

(a) A description of the internal grievance procedure required under RSA 420-J:5 for adverse determinations and other matters [which] and a description of the process for obtaining external review under RSA 420-J:5-a. These descriptions shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons.

(b) A statement of a covered person's right to contact the commissioner's office for assistance at any time. The statement shall include the toll-free telephone number and address of the commissioner.

(c) Upon written denial of a requested medical service or claim by the health carrier, a statement of the covered person's right to access the internal grievance process. This statement shall also include a written explanation of any adverse determination, with the name and credentials of the health carrier medical director, including board status and the state or states where the person is currently licensed, and the relevant clinical rationale used to make the adverse determination. If the person making the adverse determination is not the medical director but a designee, then the name, credentials, board status, and state or states of current license shall also be provided for that person. Nothing in this section shall be construed to require a health carrier to provide proprietary information protected by third party contracts. (d) Staff assistance in filing a grievance.

(e) [If requested by the consumer or health care provider acting on behalf of the consumer, a written explanation of any adverse determination, with the name and credentials of the health carrier medical director or designee, including board status and the state or states where the person is currently licensed, and the relevant clinical rationale used to make the adverse determination. Nothing in this section shall be construed to require a health carrier to provide proprietary information protected by third party contracts] Upon exhausting the second level grievance review process, a statement of the covered person's right to obtain an independent external review of the health carrier's determination. This shall include a description of the process for obtaining external review, a copy of the written procedures governing external review, including the required time frames for requesting external review, and notice of the conditions under which expedited external review is available. 7 First Level Grievance; Names Required. Amend RSA 420-J:5, III(b)(1) to read as follows:

(1) The names, titles and qualifying credentials of the persons participating in the first level grievance review process.

8 Second Level Grievance; Names Required. Amend RSA 420-J:5, V(a)(3) to read as follows:

(3) The review panel shall issue a written decision to the covered person within 5 business days of completing the review meeting. Upon concurrence of the covered person, a copy of the decision shall be forwarded to the insurance department. The decision shall include the names and titles of the members of the review panel; a statement of the review panel's understanding of the nature of the grievance, including issues raised by the covered person, and all pertinent facts; the rationale for the review panel's decision; reference to evidence or documentation considered by the review panel in making the decision; if an adverse decision is made, the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination; and a statement of the covered person's right to file an external appeal as provided in RSA [420-J:5, VIII] 420-J:5-a. The statement of appeal rights shall include a description of the process for obtaining external review of a determination, a copy of the written procedures governing external review, including the required time frames for requesting external review, and notice of the conditions under which expedited external review is available.. 9 Review Panel; Names Required. Amend RSA 420-J:5, V(b)(3) to read as follows:

(3) The review panel shall issue a written decision to the covered person within 5 business days of completing the review meeting. The decision shall include the names and titles of the members of the review panel; a statement of the review panel's understanding of the nature of the grievance and all pertinent facts; the rationale for the review panel's decision; reference to evidence or documentation considered by the review panel in making the decision; if an adverse decision is made, the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination; and a statement of the covered person's right to file an external appeal as provided in RSA [420-J:5, VIII] 420-J:5-a. The statement of appeal rights shall include a description of the process for obtaining external review of a determination, a copy of the written procedures governing external review, including the required time frames for requesting external review, and notice of the conditions under which expedited external review is available.

10 Expedited Internal Grievance Review. Amend RSA 420-J:5, VI(e) to read as follows:

(e) In any case where the expedited review process does not resolve a difference of opinion between the health carrier and the covered person or the provider acting on behalf of the covered person, the covered person or the provider acting on behalf of the covered person may submit a written grievance, unless the provider is prohibited from filing a grievance by federal or other state law. A health carrier shall review it as a second level grievance. In conducting the review, the health carrier shall [adhere to time frames that are reasonable under the circumstances] make a decision and notify the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the grievance is submitted. 11 New Paragraph; Definition Added. Amend RSA 420-J:3 by inserting after paragraph III the following new paragraph:

III-a. "Authorized representative" means any person who has obtained express written consent to represent the covered person in an external review from:

(a) The covered person;

(b) A person authorized by law to provide substituted consent for a covered person; or

(c) A family member of the covered person when adherence to the requirement of express written consent is impracticable or would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function.

12 New Paragraph; Definition Added. Amend RSA 420-J:3 by inserting after paragraph XXIII the following new paragraph:

XXIII-a. "Independent review organization" means an entity that employs or contracts with clinical peers to conduct independent external reviews of health carrier determinations.

13 New Section; External Review. Amend RSA 420-J by inserting after section 5 the following new section:

420-J:5-a External Review Process. The insurance department shall arrange for independent external review of certain health carrier determinations as follows: I. A covered person shall have the right to independent external review of a health carrier determination when the following conditions apply:

(a) The subject of the request for external review is: (1) An adverse determination; or

(2) A determination by the health carrier that a service, supply or drug is not a covered benefit, when the covered person is asserting that the service, supply or drug should be considered covered for medical reasons. This shall include, but not be limited to, the following circumstances: (A) a service, supply or drug is denied, reduced or terminated by the carrier because the health benefit plan does not cover experimental or investigational treatment, but the covered person asserts that the treatment in question should not be considered experimental or investigational.

(B) a service is denied, reduced or terminated by the carrier because the health benefit plan does not cover procedures that are performed for cosmetic reasons or for reasons of convenience, but the covered person asserts that the service is required for medical reasons rather than cosmetics or convenience.

(C) a referral is denied by the carrier because treatment by out-of-network providers is not covered unless the service in question cannot be provided within the carrier's network, and the covered person asserts that the network does not have providers with the appropriate clinical expertise for the service in question.

(D) a drug is denied by the carrier because it is not on the formulary list, but the covered person asserts that the drug is covered under the medical exception criteria.

(E) a service, supply or drug is denied because of a medically-based decision that a condition is preexisting, and the covered person disputes this. (b) The covered person has completed the internal review procedures provided by the health carrier pursuant to RSA 420-J:5, III through VI, or the health carrier has agreed to submit the determination to independent external review prior to completion of internal review, or the covered person has requested first or second level, standard or expedited review and has not received a decision from the health carrier within the required time frames.

(c) The covered person or the covered person's authorized representative has submitted the request for external review in writing to the commissioner within 12 months of the date of the health carrier's second level denial decision provided pursuant to RSA 420-J:5, V or VI, or if the health carrier has failed to make a first or second level, standard or expedited review decision that is past due, within 12 months of the date the decision was due.

(d) Except in the case of a request for expedited review, the covered person or the covered person's authorized representative has paid to the commissioner a filing fee of $25 at the time of submitting the request for external review. However, the commissioner may waive the filing fee upon a showing of financial hardship.

(e) The health carrier determination does not relate to any category of health care services that is excluded from the external review provisions of this section pursuant to paragraph II.

(f) The request for external review is not based on a claim or allegation of provider malpractice, professional negligence, or other professional fault excluded from the external review provisions of this section pursuant to paragraph III. II. Determinations relating to the following health care services shall not be reviewed under this section, but shall be reviewed pursuant to the review processes provided by applicable federal or state law: (a) Health care services provided through medicaid, the state Children's Health Insurance Program (Title XXI of the Social Security Act), medicare or services provided under these programs but through a contracted health carrier. (b) Health care services provided to inmates by the department of corrections.

(c) Health care services provided pursuant to a health plan not regulated by the state, such as self-funded plans administered by an administrative services organization or third-party administrator or federal employee benefit programs.

III. The external review procedures set forth in this section shall not be utilized to adjudicate claims or allegations of health care provider malpractice, professional negligence, or other professional fault against participating providers. IV. Standard external review shall be conducted as follows: (a) Within 7 days after the date of receipt of a request for external review, the commissioner shall complete a preliminary review of the request in order to determine whether: (1) The individual is or was a covered person under the health benefit plan; (2) The determination that is the subject of the request for external review meets the conditions of eligibility for external review stated in paragraph I; and (3) The covered person has provided all the information and forms required by the commissioner that are necessary to process an external review. (b) Upon completion of the preliminary review pursuant to subparagraph IV(a), the commissioner shall immediately notify the covered person or the covered person's authorized representative in writing: (1) Whether the request is complete; and (2) Whether the request has been accepted for external review. (c) If the request for external review is accepted, the commissioner shall:

(1) Include in the notice provided to the covered person pursuant to subparagraph IV(b) a statement that if the covered person wishes to submit new or additional information or to present oral testimony via teleconference, such information shall be submitted, and the oral testimony must be scheduled and presented, within 20 days of the date of issuance of the notice. (2) Immediately notify the health carrier in writing of the request for external review and its acceptance.

(d) If the request is not complete, the commissioner shall inform the covered person or the covered person's authorized representative what information or documents are needed to make the request complete.

(e) If the request for external review is not accepted, the commissioner shall inform the covered person or the covered person's authorized representative and the health carrier in writing of the reason for its non-acceptance. (f) At the time a request for external review is accepted, the commissioner may select an independent review organization that is certified pursuant to paragraph VI to conduct the external review. If an independent review organization is not selected to conduct the review, then the policies and procedures established by the commissioner for selecting clinical peer reviewers and conducting the review shall meet the minimum qualifications established under paragraph VII for certification of independent review organizations. (g) Within 10 days after the date of issuance of the notice provided pursuant to subparagraph IV(c)(2), the health carrier or its designated utilization review organization shall provide to the commissioner or the selected independent review organization and to the covered person all information in its possession that is relevant to the adjudication of the matter in dispute, including but not limited to:

(1) The terms of agreement of the health benefit plan, including the evidence of coverage, benefit summary or other similar document;

(2) All relevant medical records, including records submitted to the carrier by the covered person, the covered person's authorized representative, or the covered person's treating provider;

(3) A summary description of the applicable issues, including a statement of the health carrier's final determination;

(4) The clinical review criteria used and the clinical reasons for the determination;

(5) The relevant portions of the carrier's utilization management plan;

(6) Any communications between the covered person and the health carrier regarding the internal or external review; and

(7) All other documents, information, or criteria relied upon by the carrier in making its determination.

(h) In providing the information required in subparagraph IV(g), the health carrier may not present different reasons than those the health carrier or its designated utilization review organization communicated to the covered person upon internal review, unless the reasons relate to new information presented by the covered person or the covered person's authorized representative or treating provider subsequent to the internal review.

(i) Failure by the health carrier to provide the documents and information required in subparagraph IV(g) within the specified time frame shall not delay the conduct of the external review.

(j) The commissioner or the selected independent review organization shall review all of the information and documents received from the carrier pursuant to subparagraph IV(g) and any other information submitted by the covered person or the covered person's authorized representative or treating provider pursuant to subparagraph IV(c)(1) and any testimony provided. The commissioner or the independent review organization shall consider anew all previously determined facts, allow the introduction of new information, and make a decision that is not bound by decisions or conclusions made by the health carrier during internal review. In addition to the information provided by the health carrier and the covered person or the covered person's authorized representative or treating provider, the commissioner or the independent review organization may consider the following in reaching a decision:

(1) The covered person's pertinent medical records;

(2) The treating health care professional's recommendation;

(3) Consulting reports from appropriate health care professionals and other similar documents submitted by the health carrier, covered person, or the covered person's authorized representative or treating provider; (4) Any applicable, generally accepted clinical practice guidelines, including those developed by the federal government, national or professional medical societies, boards and associations;

(5) Any applicable clinical review criteria developed and used by the health carrier or its designated utilization review organization;

(6) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts;

(7) Peer-reviewed literature, biomedical compendia, and other medical literature that meet the criteria of the National Institute of Health's Library of Medicine for indexing or that are recognized by the Secretary of Health and Human Services under section 1861(t)(2) of the Social Security Act;

(8) Standard reference compendia; and

(9) Findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes. (k) The commissioner or the selected independent review organization shall render a decision upholding or reversing the determination of the health carrier and notify the covered person or the covered person's authorized representative and the health carrier in writing within 20 days of the date that any new or additional information from the covered person is due pursuant to subparagraph IV(c)(1). This notice shall include a written review decision that contains a statement of the nature of the grievance, references to evidence or documentation considered in making the decision, findings of fact, and the clinical and legal rationale for the decision, including, as applicable, clinical review criteria and rulings of law. The decision shall have the same force and effect as a final order of the commissioner and shall be enforceable pursuant to the penalty provisions of RSA 420-J:14. V. Expedited external review shall be conducted as follows: (a) Expedited external review shall be available when the covered person's treating health care provider certifies to the commissioner that adherence to the time frames specified in paragraph IV would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function.

(b) Except to the extent that it is inconsistent with the provisions of this subsection, all requirements for the conduct of standard external review specified in paragraph IV shall apply to expedited external review.

(c) At the time the commissioner receives a request for an expedited external review, the commissioner shall immediately make a determination whether the request meets the standard set forth in subparagraph V(a) for expedited external review, as well as the reviewability requirements set forth in subparagraph IV(a). If these conditions are met, the commissioner shall immediately notify the health carrier. If the request is not complete, the commissioner shall immediately contact the covered person or the covered person's authorized representative and attempt to obtain the information or documents that are needed to make the request complete.

(d) The commissioner may select an independent review organization that is certified pursuant to paragraph VI to conduct the expedited external review. If an independent review organization is not selected to conduct the review, then the policies and procedures established by the commissioner for selecting clinical peer reviewers and conducting the review shall meet the minimum qualifications established under paragraph VII for certification of independent review organizations.

(e) The health carrier or its designated utilization review organization shall provide or transmit the documents and information specified in subparagraph IV(g) to the commissioner or the selected independent review organization by telephone, facsimile or any other available expeditious method within one day of receiving the commissioner's notice of the request for expedited external review pursuant to subparagraph V(c).

(f) When handling a review on an expedited basis, the commissioner or the selected independent review organization shall make a decision and notify the carrier and the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the expedited external review is requested. The decision shall have the same force and effect as a final order of the commissioner and shall be enforceable pursuant to the penalty provisions of RSA 420-J:14.

(g) If the notice provided pursuant to subparagraph V(f) was not in writing, within 2 days after the date of providing that notice, the commissioner or the selected independent review organization shall:

(1) Provide written confirmation of the decision to the covered person or the covered person's authorized representative and the health carrier; and

(2) Include the information set forth in subparagraph IV(k).

(h) Reviews that the health carrier handled on an expedited basis in its internal review process shall be handled on an expedited basis in the external review process.

(i) An expedited external review shall not be provided for determinations made by the health carrier on a retrospective basis.

(j) Continuation of benefits pending expedited external review shall be provided when appropriate and as determined by the commissioner.

VI. The certification of independent review organizations shall be conducted as follows:

(a) The commissioner shall certify independent review organizations eligible to be selected to conduct external reviews under this section to ensure that an independent review organization satisfies the minimum qualifications established under paragraph VII.

(b) The commissioner shall develop an application form for initially certifying and recertifying independent review organizations to conduct external reviews.

(c) Independent review organizations wishing to be certified shall submit the application form and include all documentation and information necessary for the commissioner to determine whether the independent review organization satisfies the minimum qualifications established under paragraph VII.

(d) The commissioner may determine that accreditation by a nationally recognized private accrediting entity with established and maintained standards for independent review organizations that meet or exceed the minimum qualifications established under paragraph VII is sufficient for certification under this paragraph.

(e) The commissioner shall maintain and periodically update a list of certified independent review organizations.

VII. To be certified under paragraph VI to conduct external reviews, an independent review organization shall meet the following minimum qualifications:

(a) It shall develop and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process.

(b) It shall establish and maintain a quality assurance program that:

(1) Ensures that external reviews are conducted within the specified time frames and required notices are provided in a timely manner;

(2) Ensures the selection of qualified and impartial clinical peer reviewers to conduct external reviews on behalf of the independent review organization with suitable matching of reviewers to specific cases;

(3) Ensures the confidentiality of medical and treatment records; and

(4) Ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this section.

(c) It shall maintain a toll-free telephone service on a 24-hour, 7-day-a-week basis related to external reviews that is capable of accepting or recording information from, and providing appropriate instruction to callers.

(d) It shall agree to maintain and provide to the commissioner such information as may be required to fulfill the provisions and purposes of this section.

(e) It shall assign clinical peer reviewers to conduct external reviews who are physicians or other appropriate health care providers and who:

(1) Are experts in the treatment of the covered person's medical condition that is the subject of the external review;

(2) Are knowledgeable about the recommended health care service or treatment through actual clinical experience;

(3) Hold a non-restricted license in a state of the United States and, for physicians, a current certification by a specialty board recognized by the American Board of Medical Specialties in the area or areas appropriate to the subject of the external review; (4) Have no history or disciplinary actions or sanctions that have been taken or are pending by any hospital, governmental agency, or regulatory body that raise a substantial question as to the clinical peer reviewer's physical, mental or professional competence or moral character; and

(5) Have agreed to disclose any potential conflict of interest.

(f) It shall be free of any conflict of interest. To meet this qualification, an independent review organization may not own or control or in any way be owned or controlled by a health carrier, a national, state or local trade association of health carriers, or a national state or local trade association of health care providers. In addition, in order to qualify to conduct an external review of a specific case, neither the independent review organization selected to conduct the external review nor any clinical peer reviewer assigned by the independent organization to conduct the external review may have a material professional, familial or financial interest in any of the following:

(1) The health carrier that is the subject of the external review;

(2) Any officer, director or management employee of the health carrier that is the subject of the external review;

(3) The health care provider or the health care provider's medical group or independent practice association recommending the health care service or treatment that is the subject of the external review;

(4) The facility at which the recommended health care service or treatment would be provided;

(5) The developer or manufacturer of the principal drug, device, procedure or other therapy being recommended for the covered person whose treatment is the subject of the external review; or

(6) The covered person or the covered person's authorized representative. (g) For the purpose of allowing in-state health care providers to act as clinical peer reviewers in the conduct of external reviews, the commissioner may determine, in specific cases, that an affiliation with a hospital, an institution, an academic medical center, or a health carrier provider network does not in and of itself constitute a conflict of interest which is sufficient to preclude that provider from acting as a clinical peer reviewer, so long as the affiliation is disclosed to the covered person and the covered person has given his or her prior written consent.

(h) The following organizations shall not be eligible for certification to conduct external reviews:

(1) Professional or trade associations of health care providers;

(2) Subsidiaries or affiliates of such provider associations;

(3) Health carrier or health plan associations; and

(4) Subsidiaries or affiliates of health plan or health carrier associations.

VIII. A covered person shall: (a) Be provided with timely and adequate notice of his or her rights with respect to external review. (b) Have the right to be represented by any person, including the covered person's treating provider, and to otherwise make use of outside assistance during the review process, to receive a copy of all documents, all information, and all clinical review criteria or other standards relied upon by the health carrier in making its determination, and to present to the commissioner or the selected independent review organization any information, including new information not previously considered by the health carrier, which the covered person believes to be relevant to the adjudication of the matter in dispute, provided that such information is simultaneously provided to the health carrier. (c) Be provided the opportunity, under standard external review, to present oral testimony to the independent review organization via teleconference. At any such hearing, the health carrier shall also have the opportunity to present oral testimony and to respond to issues raised. (d) Be protected from retaliation for exercising the right to an independent external review under this section. IX. The health carrier against which a request for external review is filed shall pay the cost of the external review. The commissioner shall ensure that such costs assessed to the health carrier are at all times reasonable in relation to the services provided. If the covered person is the prevailing party in the external review, the health carrier shall pay to the covered person the amount of any filing fee paid by the covered person.

X. The confidentiality of any health care information acquired or provided to the commissioner or an independent review organization shall be maintained, and the records, and internal materials prepared for specific reviews by the commissioner or an independent review organization under this section shall be exempt from public disclosure under RSA 91-A.

XI. No independent review organization or clinical peer reviewer working on behalf of an independent review organization shall be liable for damages to any person for any opinions rendered during or upon completion of an external review conducted pursuant to this section, unless the opinion was rendered in bad faith or involved gross negligence.

XII. The right to external review under this section shall not be construed to change the terms of coverage under a health benefit plan.

XIII. When requested by the covered person, the commissioner shall provide consumer assistance in pursuing the internal grievance procedures and the external review process under RSA 420-J:5 and this section.

XIV. The commissioner shall report annually to the governor and the legislature on the number of grievances subjected to external review, the number of decisions resolved wholly or partially in favor of the covered person, the number of decisions resolved wholly or partially in favor of the health carrier, and any common themes or issues that may require legislative action.

XV. The commissioner shall report annually to the New Hampshire board of medicine the names of the medical directors responsible for determinations that resulted in external review and the outcomes of such external reviews. 14 New Paragraphs; Provider Contract Standards. Amend RSA 420-J:8 by inserting after paragraph VI the following new paragraphs: VII. No contract between a health carrier and a participating provider shall contain any payment or reimbursement provision the terms of which create incentives for the provider to limit medically necessary care to covered persons. Nothing in this section shall be construed to prohibit the use of payment arrangements between a health carrier and a participating provider or provider group which involve capitation or withholds. VIII. A health carrier shall provide to consumers, upon request, a description, in general terms, of the types of payment and reimbursement provisions contained in its contracts with participating providers. Such descriptions shall be set forth in clear, understandable language and shall, at a minimum, convey basic information about any financial incentives to providers that may directly or indirectly have the effect of reducing or limiting services to covered persons. IX. Every contract between a health carrier and a participating provider shall provide that the health carrier may not remove a health care provider from its network or refuse to renew the health care provider with its network for advocating on behalf of a covered person for medically necessary care for the covered person. 15 Repeal. RSA 420-J:5, VIII and IX, relative to an external process and annual report, are hereby repealed. 16 Effective Date. This act shall take effect 60 days after its passage.

1999-1730s

AMENDED ANALYSIS

This bill creates an independent external consumer appeal process to review certain determinations made by managed care entities. The bill requires health carriers that conduct utilization review and licensed utilization review entities to employ a medical director and amends the definition of the practice of medicine to include the making of certain medical necessity determinations. The bill prohibits contracts between health carriers and participating providers from including provisions that create financial incentives to deny medically necessary care. The bill also requires that health insurers disclose certain information necessary for consumers to hold managed care entities accountable for health care treatment decisions.

HB 67, relative to termination of parental rights upon a finding of either child abuse or the commission of certain criminal offenses.

Senate Conferees: Senators Pignatelli, Fernald, Squires

House Conferees: Representatives R. Lyman, I. Pratt, D. Bickford, E. Moran

HB 428, relative to school administrative units.

Senate Conferees: Senators Disnard, Johnson, J, King

House Conferees: Representatives R. McKinley, B. Ward, D. Larrabee, C. Jean

HB 491, relative to qualifying examinations for individuals seeking driver's licenses, and driver education course requirements.

Senate Conferees: Senators Gordon, Trombly, Below

House Conferees: Representatives S. Packard, R. Letourneau, G. LaPorte, J. Gleason

HB 664, establishing a study committee on rights of ownership to cemetery plots.

Senate Conferees: Senators Trombly, Disnard, Roberge

House Conferees: Representatives B. Patten, M. Griffin, R. Zerba, T. Rice

HB 689-FN, establishing a committee to study campaign contributions and expenditures.

Senate Conferees: Senators McCarley, Wheeler, Krueger

House Conferees: Representatives L. Horton, F. Davis, J. Splaine, R. Clegg

SB 30, relative to the cruelty to animals law.

Senate Conferees: Senators Wheeler, Trombly, Disnard

House Conferees: Representatives E. Weare, R. Fesh, W. Mikowlski, Welch

SB 101, relative to landlord-tenant obligations.

Senate Conferees: Senators Trombly, Disnard, Russman

House Conferees: Representatives P. Bergin, P. Woods, J. Wall, J. Craig

SB 124, establishing a committee to study the integration of technology at the state and municipal level.

Senate Conferees: Senators D'Allesandro, McCarley, Klemm

House Conferees: Representatives H. Lynde, L. Guay, R. Maxfield, L. Bergeron

SB 204, establishing the New Hampshire excellence in higher education endowment trust fund.

Senate Conferees: Senators Larsen, Gordon, Cohen

House Conferees: Representatives E. Hoadley, P. Davis, C. Snyder, J. Alger

BANKS, Room 103, LOB

9:00 a.m. HCR 7, urging the federal government not to adopt rules requiring financial institutions to monitor their customers' banking habits.

JUDICIARY, Room 102, LOB

10:15 a.m. HB 94, relative to enforcement of the child passenger restraint law.

PUBLIC AFFAIRS, Room 104, LOB

1:00 p.m. HB 399, allowing the secretary of state to have flexibility in moving the date of New Hampshire's presidential primary and changing the filing period for declarations of candidacy for candidates for president and vice-president at the presidential primary.

1:30 p.m. HB 252, establishing a committee to study all aspects of the condominium act established under RSA 356-B.

ENVIRONMENT, Room 104, LOB

2:00 p.m. HCR 11, urging Congress and the Internal Revenue Service to modify tax laws to broaden the ability of taxpayers to make tax-deductible contributions to Nuclear Decommissioning Reserve Funds.

FINANCE, Room 103, SH

9:00 a.m. HB 608-FN-A, establishing a New Hampshire emergency management response and recovery fund and making an appropriation therefor.

9:30 a.m. HB 738-FN, making an appropriation to the department of administrative services for the purpose of reimbursing counties for providing prisoner custody in courthouses.

10:00 a.m. HB 666-FN-A-L, relative to the taxation of sand, gravel, loam, and other similar substances.

10: 30 a.m. HB 684, making adjustments to the fiscal year 1999 budget for the department of health and human services.

PERFORMANCE AUDIT & OVERSIGHT COMMITTEE (RSA 17-N:1) Room 103, SH

10:00 a.m. Organizational Meeting

THE DEPARTMENT OF TRANSPORTATION Meredith Police Department, conference Room, 347 Daniel Webster Highway, Meredith

7:00 p.m. Public Officials Meeting (US 3 Parade Road)

OSTEOPOROSIS EDUCATION & ADVISORY COUNCIL (RSA 126-I:3) Room 205, LOB

9:00-12:00 Meeting

OIL FUND DISBURSEMENT BOARD (RSA 146-D:4) Room 305, LOB

9:30 a.m. Regular Meeting

DEVELOPMENTAL DISABILITY WAITLIST (RSA 171-A:1-b) Room 205, LOB

10:00 a.m. Regular Meeting

HERITAGE COLLECTIONS COMMITTEE (RSA 227-C:18) Room 208, LOB

1:00 p.m. Regular Meeting

JOINT LEGISLATIVE HISTORICAL COMMITTEE (RSA 17-I:1) Room 208, LOB

1:30 p.m. Joint Meeting

BOARD OF MANUFACTURED HOUSING (RSA 205-A:25,I) Room 201, LOB

1:00 p.m. Regular Meeting

THE DEPARTMENT OF TRANSPORTATION Plymouth regional Senior Center, 8 Depot Street, Plymouth

7:00 p.m. Public Hearing Holderness-Plymouth, Bridge Replacement NH 175A Over Pemigewasett River)

THE DEPARTMENT OF TRANSPORTATION UNH Elliot Alumni Center, The 1925 Room, Edgewood Road, Durham

7:00 p.m. Combined Public Officials/Public Informational Meeting

FISCAL COMMITTEE OF THE GENERAL COURT (RSA 14:30a,l) Room 210-211, LOB

9:00 a.m. Regular Business

9:30 a.m. Audit: State of New Hampshire, Department of Education, Special Education Catastrophic Aid Program, Performance Audit Report July 1999)

JOINT LEGISLATIVE COMMITTEE ON ADMINISTRATIVE RULES (RSA 541-A:2) Room 306-308, LOB

9:00 a.m. Meeting

NATURAL, CULTURAL & HISTORIC RESOURCE CONSERVATION COMMISSION (SB 493, Chapter 161, 1998) Room 308, LOB

1:00-4:00 Regular Meeting

THE DEPARTMENT OF TRANSPORTATION Exeter Office Building, Nowak Room, 10 Front Street, Exeter

7:00 p.m. Public Hearing (Exeter, Lincoln Street, Railroad Platform & Parking Area)

OSTEOPOROSIS EDUCATION & ADVISORY COUNCIL (RSA 126-I:3) Room 205, LOB

9:00-12:00 Meeting

JOINT LEGISLATIVE COMMITTEE ON ADMINISTRATIVE RULES (RSA 541-A:2) Room 306-308, LOB

9:00 a.m. Meeting

NATURAL, CULTURAL & HISTORIC RESOURCE CONSERVATION COMMISSION (SB 493, Chapter 161, 1998) Room 308, LOB

1:00-4:00 Regular Meeting

OSTEOPOROSIS EDUCATION & ADVISORY COUNCIL (RSA 126-I:3) Room 205, LOB

9:00-12:00 Meeting

BOARD OF CLAIMS (RSA 541-B:3) Room 202, LOB

8:30-5:00 Regular Meeting

JOINT LEGISLATIVE COMMITTEE ON ADMINISTRATIVE RULES (RSA 541-A:2) Room 306-308, LOB

9:00 a.m. Meeting

NATURAL, CULTURAL & HISTORIC RESOURCE CONSERVATION COMMISSION (SB 493, Chapter 161, 1998) Room 308, LOB

1:00-4:00 Regular Meeting

OSTEOPOROSIS EDUCATION & ADVISORY COUNCIL (RSA 126-I:3) Room 205, LOB

9:00-12:00 Meeting

JOINT LEGISLATIVE COMMITTEE ON ADMINISTRATIVE RULES (RSA 541-A:2) Room 306-308, LOB

9:00 a.m. Meeting

OSTEOPOROSIS EDUCATION & ADVISORY COUNCIL (RSA 126-I:3) Room 205, LOB

9:00-12:00 Meeting

JOINT LEGISLATIVE COMMITTEE ON ADMINISTRATIVE RULES (RSA 541-A:2) Room 306-308, LOB

9:00 a.m. Meeting

OSTEOPOROSIS EDUCATION & ADVISORY COUNCIL (RSA 126-I:3) Room 205, LOB

9:00-12:00 Meeting

JOINT LEGISLATIVE COMMITTEE ON ADMINISTRATIVE RULES (RSA 541-A:2) Room 306-308, LOB

9:00 a.m. Meeting

New Hampshire Women's Forum (a non partisan political organization) Is Hosting Congressman Charles Bass At The Langdon Place Of Nashua, 319 East Dunstable Road, Nashua, On June 25^th At 7:00 p.m. Coffee And Desert Will Be Served.

Directions: Langdon Place Is Off Exit 1 Of The Everett Turnpike South. After Exit Take A Right And Langdon Place Of Nashua Is On The Left Past Sky Meadow.

Senator Gary Francoeur