T41CH59
Title 41 > T41CH59
Sections (17)
41-5901
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5901. short title. This chapter shall be known and may be cited as the Idaho Health Carrier External Review Act. History: [41-5901, added 2009, ch. 87, sec. 1, p. 240.]
41-5902
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5902. purpose and intent. The purpose of this chapter is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of a final adverse benefit determination, as defined in this chapter. History: [41-5902, added 2009, ch. 87, sec. 1, p. 240.]
41-5903
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5903. definitions. For purposes of this chapter: (1) Administrative record means all nonprivileged documents, records or other health information which was submitted, considered, generated or relied upon by the health carrier in the course of making the adverse benefit determination, including, but not limited to, documents, records or other information that constitutes the plan’s policy statements or guidance concerning the denied treatment or benefit, all records provided by the covered person or the covered person’s medical care provider related to the denied treatment or benefit, all records provided to an independent review organization as part of the independent review of the denied treatment or benefit and the opinion issued by the independent review organization. (2) Adverse benefit determination means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness or has been determined to be an investigational service, and the requested service or payment for the service is therefore terminated, denied or reduced. (3) Ambulatory review means utilization review of health care services performed or provided in an outpatient setting. (4) Authorized representative means: (a) A person to whom a covered person has given express written consent to represent the covered person in an external review; (b) A person authorized by law to provide substituted consent for a covered person; or (c) A family member of the covered person or the covered person’s treating health care professional only when the covered person is unable to provide consent. (5) Best evidence means evidence based on randomized clinical trials. (a) If randomized clinical trials are not available, then cohort studies or case-control studies; (b) If studies in paragraph (a) of this subsection (5) are not available, then case-series. (6) Case-control study means a retrospective evaluation of two (2) groups of patients with different outcomes to determine which specific interventions the patients received. (7) Case management means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions. (8) Case-series means an evaluation of a series of patients with a particular outcome, without the use of a control group. (9) Certification means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based on the information provided, satisfies the health carrier’s requirements for medic
41-5904
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5904. applicability and scope. (1) Except as provided in subsection (2) of this section, this chapter shall apply to all health carriers. (2) The provisions of this chapter shall not apply to a plan, policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage; nor shall this chapter apply to a credit, dental, disability income, hospital indemnity, long-term care insurance, vision care, limited benefit health plans or any other limited supplemental benefit; nor shall this chapter apply to a medicare advantage plan or medicare supplemental policy of insurance, as defined by the director by rule, coverage under a plan through medicare, medicaid, or the federal employees health benefits program, any coverage issued under chapter 55, title 10, of the United States Code and any coverage issued as supplemental to that coverage; nor shall this chapter apply to any coverage issued as supplemental to liability insurance, worker’s compensation or similar insurance, automobile medical payment insurance or any insurance under which benefits are payable with or without regard to fault, whether written on a group blanket or individual basis; nor shall this chapter apply to a single employer self-funded employee benefit plan subject to and operated in compliance with the employee retirement income security act of 1974 (ERISA); provided however, the single employer self-funded ERISA employee benefit plan administrator or designee may, by timely and appropriate written notice to the director, voluntarily elect to comply with the provisions of this chapter either for a single plan beneficiary or for a specific period of time. The director may promulgate rules establishing the procedure for an employee benefit plan administrator or designee, to voluntarily comply with the provisions of this chapter and to provide for an administrative fee to be paid by the employee benefit plan administrator for each voluntary external review request submitted to the department pursuant to this chapter. (3) The availability or use of external review pursuant to this chapter shall not alter the standard of review used by a court of competent jurisdiction when adjudicating the health carrier’s final adverse benefit determination. History: [41-5904, added 2009, ch. 87, sec. 1, p. 245; am. 2011, ch. 122, sec. 2, p. 337; am. 2011, ch. 258, sec. 1, p. 703.]
41-5905
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5905. notice of right to external review. (1) When a final adverse benefit determination is made, the health carrier shall notify the covered person in writing of the covered person’s right to request an external review to be conducted pursuant to section 41-5908 , 41-5909 or 41-5910 , Idaho Code, and include the appropriate statements and information set forth in subsection (2) of this section at the same time the health carrier sends written notice of the final adverse benefit determination. (2) The director may prescribe by rule the form and content of the notice required under this section, which shall include: (a) The following, or substantially equivalent, language: We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of your health care service or supply, or your health care service or supply was denied based upon a determination that it was investigational. You may request an external review by submitting a written request to the department of insurance. The notice shall include contact information for the department of insurance, including the website, address and telephone number. (b) If the adverse benefit determination is for a pre-service or concurrent service, the health carrier shall notify the covered person of the right to an expedited external review if the request is an urgent care request. The notification shall include the definition of urgent care request. (c) The health carrier shall include a copy of the description of both the standard and expedited external review procedures the health carrier is required to provide pursuant to section 41-5916 , Idaho Code, highlighting the provisions in the external review procedures that give the covered person the opportunity to submit additional information, and include any forms used to process an external review. (d) The health carrier shall include an authorization form, or other document approved by the director, that complies with the requirements of 45 CFR section 164.508, by which the covered person, for purposes of conducting an external review pursuant to this chapter, authorizes the health carrier and the covered person’s treating health care providers to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review. Until the director receives this form from the covered person, duly executed, the external review process is stayed and the health carrier has no obligations under this chapter. History: [41-5905, added 2009, ch. 87, sec. 1, p. 245; am. 2011, ch. 122, sec. 3, p. 338.]
41-5906
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5906. request for external review. A covered person may make a request for an external review of a final adverse benefit determination. Except for a request for an expedited external review as set forth in section 41-5909 , Idaho Code, all requests for external review shall be made in writing to the director. The director may prescribe by rule the form and content of external review requests required to be submitted under this section. History: [41-5906, added 2009, ch. 87, sec. 1, p. 246; am. 2011, ch. 122, sec. 4, p. 339.]
41-5907
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5907. Exhaustion of internal grievance process. (1) Except as provided in subsection (2) of this section, a request for an external review pursuant to section 41-5908 , 41-5909 or 41-5910 , Idaho Code, shall not be made until the covered person has exhausted the health carrier’s internal grievance process. A covered person shall be considered to have exhausted the health carrier’s internal grievance process for purposes of this section, if the covered person: (a) Has filed and completed a grievance, involving an adverse benefit determination, according to the terms and conditions of the covered person’s health benefit plan; or (b) Except to the extent the covered person requested or agreed to a delay, has not received a written decision on the grievance from the health carrier within thirty-five (35) days following the date the covered person filed the grievance with the health carrier, or the covered person filed a grievance on an urgent care request on a pre-service or concurrent care adverse benefit determination and has not received a determination from the health carrier within three (3) business days after filing. (2) A request for an external review of an adverse benefit determination may be made before the covered person has exhausted the health carrier’s internal grievance procedures as set forth in the health carrier’s grievance appeal process whenever: (a) The health carrier agrees to waive the exhaustion requirement; (b) The health carrier has failed to strictly follow its duties in affording a timely, full and fair opportunity for the covered person to take advantage of the internal grievance procedures; or (c) The urgent care request involves a medical condition for which the time frame for completion of the carrier’s internal grievance process pursuant to this section would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, and the covered person has applied for expedited external review at the same time as applying for an expedited internal review. History: [41-5907, added 2009, ch. 87, sec. 1, p. 246; am. 2011, ch. 122, sec. 5, p. 339.]
41-5908
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5908. standard external review. (1) Within four (4) months after the date of issuance of a notice of a final adverse benefit determination pursuant to section 41-5905 , Idaho Code, a covered person may file a request for an external review with the director. The request shall be made on such form as may be designated by the director. (2) Within seven (7) days after the date of receipt of a request for external review pursuant to subsection (1) of this section, the director shall send a copy of the request to the health carrier. (3) Within fourteen (14) days following the date of receipt of the copy of the external review request from the director pursuant to subsection (2) of this section, the health carrier shall complete a preliminary review of the request to determine whether: (a) The individual is or was a covered person in the health benefit plan at the time the health care service was requested or, in the case of a post service review, was a covered person in the health benefit plan at the time the health care service was provided; (b) The health care service that is the subject of the final adverse benefit determination is a covered service under the covered person’s health benefit plan, but for a determination by the health carrier that the health care service is not covered because it does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness or the service or supply is investigational; (c) The covered person has exhausted the health carrier’s internal grievance process as set forth in the covered person’s health benefit plan, unless the covered person is not required to exhaust the health carrier’s internal grievance process pursuant to section 41-5907 , Idaho Code; and (d) The covered person has provided all the information and forms required to process an external review, including the release form provided under section 41-5905 (2)(d), Idaho Code. (4) Within five (5) business days after completion of the preliminary review, the health carrier shall notify the director and covered person in writing whether the request is complete and whether the request is eligible for external review. (5) If the request is not complete, the health carrier shall inform the covered person and the director in writing and include in the notice what information or materials are needed to make the request complete. (6) If the request is not eligible for external review, the health carrier shall inform the covered person and the director in writing and include in the notice the reasons for its ineligibility. (7) The director may prescribe by rule the form for the health carrier’s notice of initial determination under this section and any supporting information to be included in the notice. The notice of initial determination shall include a statement informing the covered person that a health carrier’s init
41-5909
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5909. expedited external review. (1) A covered person may make a request for an expedited external review of a pre-service or concurrent service adverse benefit determination where the requested service meets the definition of an urgent care request and the covered person has exhausted the health carrier’s internal grievance process or is entitled to request external review before exhausting the health carrier’s internal grievance process as provided in section 41-5907 , Idaho Code. (2) Upon receipt of a request for an expedited external review, the director shall send a copy of the request to the health carrier. (3) Upon receipt of the request pursuant to subsection (2) of this section, the health carrier shall determine, as soon as possible but not later than the second full business day thereafter, whether the carrier agrees that the request meets the reviewability requirements set forth in section 41-5908 (3), Idaho Code. The health carrier shall notify the director and the covered person of its eligibility determination as soon as reasonably practicable but not later than one (1) business day after making the determination. (a) The director may prescribe by rule the form for the health carrier’s notice of initial determination under this subsection and any supporting information to be included in the notice. (b) The notice of initial determination shall include a statement informing the covered person that a health carrier’s initial determination that an external review request is ineligible for review, may be appealed to the director. (4) The director may determine that a request is eligible for external review pursuant to section 41-5908 (3), Idaho Code, notwithstanding a health carrier’s initial determination that the request is ineligible, and require that it be referred for external review. In making a determination under this subsection (4), the director’s decision shall be made in accordance with the applicable procedural requirements of this chapter and the terms and conditions of the covered person’s health benefit plan. (5) Upon receipt of the notice that the request meets the reviewability requirements, the director shall assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations compiled and maintained by the director pursuant to section 41-5911 , Idaho Code. The director shall notify the health carrier and the covered person of the name of the assigned independent review organization. (6) In reaching a decision in accordance with subsection (9) of this section, the assigned independent review organization is not bound by the exercise of discretion or any decisions or conclusions reached during the health carrier’s internal grievance process. (7) Upon receipt of the notice from the director of the name of the independent review organization assigned to conduct the expedited e
41-5910
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5910. binding nature of external review decision. (1) For a health care benefit plan not subject to the employee retirement income security act of 1974 (ERISA), the external review decision is final and binding on the health carrier and on the covered person. No judicial action or proceeding arising out of the external review decision or the issues determined by the external review decision shall be permitted. For a health care benefit plan subject to ERISA, the external review decision is final and binding on the health carrier; however, should the covered person seek judicial review of the external review decision, then the external review record and decision shall be included as a part of the administrative record for the purpose of review by any court of competent jurisdiction. (2) A covered person may not file a subsequent request for external review involving the same adverse benefit determination or final adverse benefit determination for which the covered person has already received an external review decision pursuant to this chapter. History: [41-5910, added 2009, ch. 87, sec. 1, p. 252.]
41-5911
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5911. approval of independent review organizations. (1) The director shall approve independent review organizations eligible to be assigned on a random basis to conduct external reviews under this chapter. (2) In order to be eligible for approval by the director under this section to conduct external reviews under this chapter an independent review organization shall: (a) Except as otherwise provided in this section, be accredited by a nationally recognized private accrediting entity that the director has determined has independent review organization accreditation standards that are equivalent to or exceed the minimum qualifications for independent review organizations established under section 41-5912 , Idaho Code; and (b) Submit an application for approval in accordance with subsection (4) of this section. (3) The director shall develop an application form for initially approving and for reapproving independent review organizations to conduct external reviews. (4) Any independent review organization wishing to be approved to conduct external reviews under this chapter shall submit the application form and include with the form all documentation and information necessary for the director to determine whether the independent review organization satisfies the minimum qualifications established under section 41-5912 , Idaho Code. (5) The director shall publish prominently on the department of insurance website notice of a submitted application or reapplication by an independent review organization to provide external reviews under this chapter. (a) Any person wishing to comment on an application shall have forty-two (42) days, from the publication of notice by the director, to provide written comments to the director on the application or reapplication submitted by an independent review organization. (b) The director shall review and consider the written comments received in determining whether to approve the application or reapplication of an independent review organization. (c) The director may approve independent review organizations that are not accredited by a nationally recognized private accrediting entity if there are no acceptable nationally recognized private accrediting entities providing independent review organization accreditation. (6) The director may charge an application fee that independent review organizations shall submit to the director with an application for approval and reapproval. (7) An approval is effective for two (2) years, unless the director determines before its expiration that the independent review organization no longer satisfies the minimum qualifications established under section 41-5912 , Idaho Code. (8) The director shall maintain and periodically update a list of approved independent review organizations. Whenever the director determines that an independent review organization has lost its accreditation or no longer satisfies the minim
41-5912
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5912. minimum qualifications for independent review organizations. (1) To be approved to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in this chapter that include, at a minimum: (a) A quality assurance mechanism in place that: (i) Ensures that external reviews are conducted within the specified time frames and that required notices are provided in a timely manner; (ii) Ensures the selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the independent review organization and suitable matching of reviewers to specific cases and that the independent review organization employs or contracts with an adequate number of clinical reviewers to meet this objective; (iii) Ensures the confidentiality of medical and treatment records and clinical review criteria; and (iv) Ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this chapter; (b) A toll free telephone service to receive information on a twenty-four (24) hour day, seven (7) day a week basis related to external reviews that is capable of accepting, recording or providing appropriate instruction to incoming telephone callers during other than normal business hours; and (c) An agreement to maintain and provide to the director the information set out in section 41-5914 , Idaho Code. (2) All clinical reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other appropriate health care providers who meet the following minimum qualifications: (a) Be an expert in the treatment of the covered person’s medical condition that is the subject of the external review; (b) Be knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person; (c) Hold a nonrestricted license in a state of the United States and, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review; and (d) Have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit or regulatory body that raise a substantial question as to the clinical reviewer’s physical, mental or professional competence or moral character. (3) In addition to the requirements set forth in subsection (1) of this section, an independent review organization may not own or control, be a subsidiary of or in any way be owned or controlled by, or exercise control with a health benef
41-5913
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5913. hold harmless for independent review organizations. No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent or contractor of an independent review organization shall be liable in damages or otherwise to any person for any opinions rendered or acts or omissions performed within the scope of the organization’s or person’s duties under the law during or upon completion of an external review conducted pursuant to this chapter unless the opinion was rendered or act or omission performed in bad faith or involved gross negligence; provided that the health carrier shall not be liable in damages or otherwise to any person for any opinions rendered or acts or omissions performed by the independent review organization, its employees, agents or contractors within the scope of the organization’s or person’s duties under the law during or upon completion of an external review conducted pursuant to this chapter. History: [41-5913, added 2009, ch. 87, sec. 1, p. 255.]
41-5914
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5914. external review reporting requirements. (1) An independent review organization assigned pursuant to this chapter to conduct an external review shall maintain written records in the aggregate for Idaho by health carrier on all requests for external review for which it conducted an external review during a calendar year and, upon request, submit a report to the director, as required under this section. Each independent review organization required to maintain written records on all requests for external review pursuant to this section for which it was assigned to conduct an external review shall submit to the director, upon request or at specified intervals, a report in the format specified by the director. (2) The report shall include in the aggregate for Idaho for each health carrier: (a) The total number of requests for external review; (b) The number of requests for external review resolved and, of those resolved, the number resolved upholding the final adverse benefit determinations and the number resolved reversing the final adverse benefit determinations; (c) The average length of time for resolution; (d) A summary of the types of coverages or cases for which an external review was sought; (e) The number of external reviews pursuant to section 41-5908 (18), Idaho Code, that were terminated as the result of a reconsideration by the health carrier of its final adverse benefit determination after the receipt of additional information from the covered person; and (f) Any other information the director may reasonably request or require. (3) The independent review organization shall retain the written records required pursuant to this section for at least five (5) years. (4) Each health carrier shall maintain written records in the aggregate for Idaho for each type of health benefit plan offered by the health carrier on all requests for external review that the health carrier receives notice of from the director pursuant to this chapter. (5) Each health carrier is required to maintain written records on all requests for external review pursuant to subsection (1) of this section and shall submit to the director, upon request or at specified intervals, a report in the format specified by the director. The report shall include in the aggregate for Idaho and by type of health benefit plan: (a) The total number of requests for external review; (b) From the total number of requests for external review reported, the number of requests determined eligible for a full external review; and (c) Any other information the director may reasonably request or require. (6) The health carrier shall retain the written records required pursuant to this section for at least five (5) years. History: [41-5914, added 2009, ch. 87, sec. 1, p. 255.]
41-5915
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5915. funding of external review. The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the reasonable cost of the independent review organization for conducting the external review. History: [41-5915, added 2009, ch. 87, sec. 1, p. 256; am. 2011, ch. 122, sec. 8, p. 345.]
41-5916
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5916. disclosure requirements. (1) Each health carrier shall include a summary description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage it provides to covered persons. The disclosure shall be in a format prescribed by the director. (2) The description required under subsection (1) of this section shall include: (a) A statement that informs the covered person of the right of the covered person to file a request for an external review of a final adverse benefit determination with the director; (b) An explanation that external review and, in certain circumstances, expedited external review are available when the final adverse benefit determination involves an issue of medical necessity, appropriateness, health care setting, level of care, effectiveness or investigational service or supply; (c) The website, telephone number and address of the director; and (d) A statement informing the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review including any judicial review of the external review decision pursuant to ERISA, if applicable. (e) If the health plan is not subject to ERISA, a statement informing the covered person that the plan is not subject to ERISA and that if the covered person elects to request external review, the external review decision of the independent review organization shall be final and binding on both the covered person and the health carrier, as provided in section 41-5910 , Idaho Code. If the health plan is subject to ERISA, the statement shall inform the covered person that the plan is subject to ERISA and that if the covered person elects to request external review, the external review decision of the independent review organization shall be final and binding on the health carrier but not the covered person, as provided in section 41-5910 , Idaho Code, and that the covered person may have the right to judicial review under ERISA in a court of competent jurisdiction. History: [41-5916, added 2009, ch. 87, sec. 1, p. 256; am. 2011, ch. 122, sec. 9, p. 345.]
41-5917
TITLE 41 INSURANCE CHAPTER 59 IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT 41-5917. SEVERABILITY. The provisions of this act are hereby declared to be severable and if any provision of this act or the application of such provision to any person or circumstance is declared invalid for any reason, such declaration shall not affect the validity of the remaining portions of this act. History: [41-5917, added 2009, ch. 87, sec. 1, p. 257.]