420-J:5-b Standard External Review. –
Standard external review shall be conducted as follows:
I. Within 7 business days after the date of receipt of a request for external review, the commissioner shall complete a preliminary review of the request to determine whether:
(a) The individual is or was a covered person under the health benefit plan;
(b) The determination that is the subject of the request for external review meets the conditions of eligibility for external review stated in RSA 420-J:5-a, I; and
(c) The covered person has provided all the information and forms required by the commissioner that are necessary to process a request for an external review.
II. Upon completion of the preliminary review pursuant to paragraph I, the commissioner shall immediately notify the covered person or the covered person's authorized representative in writing:
(a) Whether the request is complete; and
(b) Whether the request has been accepted for external review.
III. 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 and to process the request. The covered person or the covered person's authorized representative shall submit such information or documentation within 10 days of being notified that the request was incomplete.
IV. If the request for external review is accepted, the commissioner shall:
(a) Include in the notice provided to the covered person pursuant to paragraph II 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 shall be scheduled and presented, within 20 days of the date of issuance of the notice. However, the notice shall also explain that oral testimony shall be permitted only in cases when the commissioner determines, based on evidence provided by the covered person, that it would not be feasible or appropriate to present only written testimony.
(b) Immediately notify the health carrier in writing of the request for external review and its acceptance.
V. 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.
VI. At the time a request for external review is accepted, the commissioner shall select and retain an independent review organization that is certified pursuant to RSA 420-J:5-d, I to conduct the external review. The commissioner shall not select the same independent review organization for each external review, but shall rotate among the certified independent review organizations, using all organizations equally. The commissioner may select and retain an independent review organization regardless of the rotation if the commissioner determines that the use of such independent review organization is necessary for the fair adjudication of the case in question.
VII. Within 10 days after the date of issuance of the notice provided pursuant to subparagraph IV(b), the health carrier or its designated utilization review organization shall provide to 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:
(a) The terms of agreement of the health benefit plan, including the evidence of coverage, benefit summary, or other similar document;
(b) 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;
(c) A summary description of the applicable issues, including a statement of the health carrier's final determination;
(d) The clinical review criteria used and the clinical reasons for the determination;
(e) The relevant portions of the carrier's utilization management plan;
(f) Any communications between the covered person and the health carrier regarding the internal or external review; and
(g) All other documents, information, or criteria relied upon by the carrier in making its determination.
VIII. Failure by the health carrier or the covered person to provide the documents and information required in paragraph IV(a) or VII within the specified time frame shall not delay the conduct of the external review.
IX. The selected independent review organization shall review all of the information and documents received from the carrier pursuant to paragraph VII and any other information submitted by the covered person or the covered person's authorized representative or treating provider with the request for external review or pursuant to subparagraph IV(a) and any testimony provided . 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 independent review organization may consider any applicable, generally accepted clinical practice guidelines, studies or research, including those developed or conducted by the federal government, national or professional medical societies, boards, and associations. 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.
X. 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(a). 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.