Section 22-B6003. FORMAL INTERNAL REVIEW

 

6003.1A member or member representative dissatisfied with the grievance decision rendered in the informal internal review process may seek a formal internal review before a reviewer, physician, or panel of physicians, advanced practice registered nurses, or other health care professionals selected by the insurer based upon the specific issues presented by the grievance.

 

6003.2Each request for a formal internal review shall be acknowledged by the insurer, in writing, to the member or member representative within ten (10) business days of receipt.

 

6003.3A reviewer physician or member of a panel selected by the insurer pursuant to § 6003.1 shall not have been involved in the grievance decision under review.

 

6003.4In all reviews requiring medical expertise, the reviewer or panel shall include at least one medical reviewer trained and certified, by a recognized specialty board listed in the current Directory of Medical Specialists, in the same specialty as the matter at issue.

 

6003.5Each medical reviewer shall be a physician or an advanced practice registered nurse or other health care provider possessing a nonrestricted license to practice or provide care anywhere in the United States and have no history of disciplinary action or sanctions pending or taken against them by any governmental or professional regulatory body.

 

6003.6 Each formal internal review shall be concluded as soon as possible after receipt of all necessary documentation by the insurer, but in no event later than thirty (30) business days after the insurer has received notice of the request for a formal internal review, except as provided in § 6003.7.

 

6003.7If the formal internal review is from a decision regarding an emergency or urgent medical condition, the insurer shall complete the review within twenty-four (24) hours of the receipt of the request for a formal internal review.

 

6003.8An insurer shall determine within ten (10) business days of the filing of a request for a formal internal review whether the insurer has sufficient information to complete its review process. If the information is insufficient, the insurer shall:

 

(a)Notify the member or member representative who filed the grievance that it cannot proceed with the grievance unless additional information is provided;

 

(b)Specify all additional information required to be filed; and

 

(c)Assist the member or member representative in gathering the necessary information without further delay.

 

6003.9The time within which an insurer must render a decision pursuant to this section may be extended only upon the written request of the member or member representative.

 

6003.10If a grievance decision by the insurer after a formal internal review is adverse to the member, the insurer shall provide the member or member representative with a written explanation of the decision and notification of the member's right to seek a formal external review of the decision.

 

6003.11The written notification required by § 6003.10 shall include:

 

(a)The reviewer's understanding of the grievance;

 

(b)The reviewer's decision in clear terms;

 

(c)The contractual basis or medical reason in sufficient detail for the member or member representative to understand and respond to the insurer's position, provided that general terms such as "experimental procedures not covered", "cosmetic procedures not covered", "service included under another procedure", and "not medically necessary" shall not be used, unless reference is made to a specific contract provision or medical evidence that verifies the insurer's position; and

 

(d)All pertinent instructions, in at least 12 point type face, including the telephone numbers and titles of persons to contact, any forms required to initiate an external review, and applicable time frames to request a formal external review of the decision.

 

6003.12If the insurer fails to comply with any deadline for completion of a formal internal review, the member or member representative shall be relieved of the duty to exhaust the formal internal review process, and may proceed directly to the external review process.

 

source

Final Rulemaking published at 47 DCR 229 (January 14, 2000).