420-J:5-c Expedited External Review. –
Expedited external review shall be conducted as follows:
I. 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 RSA 420-J:5-b would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function.
II. Except to the extent that it is inconsistent with the provisions of this paragraph, all requirements for the conduct of standard external review specified in RSA 420-J:5-b shall apply to expedited external review. However, a person who meets the standard set forth in paragraph I for expedited external review, as well as the reviewability requirements set forth in RSA 420-J:5-b, I, may pursue expedited external review simultaneous with the internal review process in RSA 420-J:5.
III. 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 paragraph I for expedited external review, as well as the reviewability requirements set forth in RSA 420-J:5-b, I. 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.
IV. The commissioner shall select and retain an independent review organization that is certified pursuant to RSA 420-J:5-d, I to conduct the expedited external review.
V. The health carrier or its designated utilization review organization shall provide or transmit the documents and information specified in RSA 420-J:5-b, VII to the selected independent review organization by telephone, facsimile, or any other available expeditious method within one business day of receiving the commissioner's notice of the request for expedited external review pursuant to paragraph III.
VI. When handling a review on an expedited basis, 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.
VII. If the notice provided pursuant to paragraph VI was not in writing, within 2 business days after the date of providing that notice, the selected independent review organization shall:
(a) Provide written confirmation of the decision to the covered person or the covered person's authorized representative and the health carrier; and
(b) Include the information set forth in RSA 420-J:5-b, X.
VIII. An expedited external review shall not be provided for determinations made by the health carrier on a retrospective basis.
IX. A covered person shall not be held liable to either the health plan, the hospital, the physician, or the services provider for the cost of services in excess of the applicable copayment, coinsurance, or deductible incurred, pending the independent review organization's determination of an expedited external review.
Source. 2000, 18:13. 2012, 98:2, eff. July 28, 2012.