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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-B6007. EXTERNAL REVIEW OF ADVERSE GRIEVANCE DECISIONS
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6007.1Upon the filing of a request for an external review, the Director shall make the determinations required under §107(c) of the Act, D.C. Code, 2001 Ed. §44-301.07(c), and shall notify the member, member representative and insurer in writing, within five (5) business days, as to whether the request has been accepted for processing.
6007.2In responding to an external review an insurer may not rely on any basis not stated in its internal grievance decision, except that the Director may allow an insurer, a member or member representative to provide supplemental information as may be relevant for the IRO to make a final decision on the grievance.
6007.3If a request for external review is not accepted, the Director shall provide a written statement of the denial to the member, the member representative and the insurer within five (5) business days of its filing. In emergency or urgent medical condition cases, such statement shall be provided within twenty-four (24) hours.
6007.4If the request is accepted, the Director shall assign the external review to a certified IRO, on a rotating basis, for a full review after verifying that the IRO conducting the review has no material professional, familial, or financial conflict with any person or entity specified in § 108(f)(1) of the Act, D.C. Code, 2001 Ed. §44-301.08(f)(1).
6007.5The Director shall deny an assignment to an IRO if the Director determines that making an assignment would result in a conflict of interest or would create an appearance of impropriety.
6007.6The Director, upon receipt of the IRO's recommendations, shall forward copies of the recommendation to the member, the member representative and the insurer.
6007.7The Director may refer matters not within the Director's jurisdiction to any other appropriate federal or District government agency for disposition or resolution, including but not limited to the Department of Insurance and Securities Regulation and the Office of Fair Hearings.