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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 22. HEALTH |
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SubTilte 22-B. PUBLIC HEALTH AND MEDICINE |
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Chapter 22-B60. HEALTH BENEFITS PLAN MEMBERS BILL OF RIGHTS |
Section 22-B6004. EXPEDITED REVIEW PROCESS IN EMERGENCY OR URGENT MEDICAL CONDITION CASES
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6004.1An expedited review is required for an adverse decision involving an emergency or urgent medical condition in accordance with this section if:
(a)The adverse decision is rendered for health care services that are proposed but have not been delivered; and
(b)The services are necessary to treat a condition or illness that, without prompt or immediate medical attention, would place the health of the individual in serious jeopardy, result in serious impairment to bodily functions, result in serious dysfunction of any bodily organ or jeopardize the life or health of the member or the member's ability to regain maximum function, or cause the member to be a danger to self or others.
6004.2In emergency or urgent medical condition cases, the insurer shall send notice in writing of any adverse decision to the member or the member representative within one (1) business day after a decision has been orally communicated to the member or member representative.
6004.3An insurer shall render a final grievance decision in an emergency or urgent medical condition case within twenty-four (24) hours after the grievance was filed pursuant to the insurer's internal grievance process.
6004.4The content of any written notice by an insurer of an adverse grievance decision under these rules shall comply with § 6001.4 of this Chapter.
6004.5In emergency or urgent medical condition cases, a request for an external review may be filed with the Director if a grievance decision reached in an informal or formal internal review is not rendered within twenty-four (24) hours after the filing of the grievance pursuant to the insurer's internal grievance process.
6004.6After external review of a grievance by an independent review organization (“IRO”) in an emergency or urgent medical condition case, the Director shall send written notice to all parties of the IRO's recommendations within twenty-four (24) hours after the Director or the Director's designee has informed the member or member representative and the insurer of the recommendation through an oral communication.