1. (a) A covered person or the covered person's authorized representative may make a request to the director for an external review of an adverse determination or a final adverse determination. Except for a request for an expedited external review, a covered person or the covered person's authorized representative shall submit a request for an external review to the director not later than 180 days after the covered person or the covered person's authorized representative receives notice of the adverse determination. The director will extend the 180-day time period for filing the request if the

   1. (1) covered person or the covered person's authorized representative files a written request with the director seeking an extension; and
   2. (2) the request for the extension sets out one or more justifications for the extension that a prudent person would consider to be a fair and reasonable basis for allowing the extension; the covered person or the covered person's authorized representative does not need to file the request for an extension under this subsection within the 180-day filing period.
2. (b) A covered person or the covered person's authorized representative may submit a written request for an external review to the director by contacting the division by mail, electronic mail, or facsimile transmission. A written request for an external review must include a copy of the health care insurer's written notice containing the adverse determination or final adverse determination.
3. (c) A covered person or the covered person's authorized representative may make an oral request to the director for an expedited external review by telephoning the division. The director may require submission of additional documents or information, including physician certifications or medical information releases considered practicable under the time constraints.
4. (d) There is no charge for submitting a request for an external review.

(Eff. 3/15/2018, Register 225)