(a)

1. (1) A 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 23 CAR § 117-107, 23 CAR § 117-108, or 23 CAR § 117-109 and include the appropriate statements and information set forth in subsection (b) of this section at the same time the health carrier sends written notice of:

   1. (A) An adverse determination upon completion of the health carrier’s utilization review process; and
   2. (B) A final adverse determination.
2. (2) As part of the written notice required under subdivision (a)(1) of this section, a health carrier shall include the following, or substantially equivalent, language: We have denied your request for the provision of or payment for a healthcare service or course of treatment. You may have the right to have our decision reviewed by healthcare professionals who have no association with us if our decision involved making a judgment as to the medical necessity (or substantially equivalent term), appropriateness, healthcare setting, level of care, or effectiveness of the healthcare service or treatment you requested by submitting a request for external review in writing to the Insurance Commissioner at 1 Commerce Way, Little Rock, AR 72202-2087 or by calling 1-800-852-5494 or 1-501-371-2600.
3. (3) The Insurance Commissioner may otherwise prescribe the form and content of the notice as required under this section by bulletin, directive, or other publication to health carriers.

(b)

1. (1) The health carrier shall include in the notice required under subsection (a) of this section:

   1. (A) For a notice related to an adverse determination, a statement informing the covered person that:

(i) If the covered person has a medical condition where the time frame for completion of an expedited review of an appeal involving an adverse determination set forth in the health carrier’s internal appeal procedure or utilization review procedure would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or the covered person’s authorized representative may file a request for an expedited external review to be conducted pursuant to 23 CAR § 117-108 or 23 CAR § 117-109 if the adverse determination involves a denial of coverage based on a determination that the recommended or requested healthcare service or treatment is experimental or investigational and the covered person’s treating physician certifies in writing that the recommended or requested healthcare service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated, at the same time the covered person or the covered person’s authorized representative files a request for an expedited review of an appeal involving an adverse determination as set forth in the health carrier’s internal appeal procedure or utilization review procedure, but that the independent review organization assigned to conduct the expedited external review will determine whether the covered person shall be required to complete the expedited review of the appeal prior to conducting the expedited external review; and

1. (ii) The covered person or the covered person’s authorized representative may file an appeal under the health carrier’s internal appeal process, but if the health carrier has not issued a written decision to the covered person or the covered person’s authorized representative within thirty (30) days following the date the covered person or the covered person’s authorized representative files the appeal with the health carrier for a preservice claim or sixty (60) days for a post-service claim and the covered person or the covered person’s authorized representative has not requested or agreed to a delay, the covered person or the covered person’s authorized representative:

(b) (b) Shall be considered to have exhausted the health carrier’s internal appeal process for purposes of 23 CAR § 117-106; and

1. (B) For a notice related to a final adverse determination, a statement informing the covered person that:

   1. (i) If the covered person has a medical condition where the timeframe for completion of a standard external review pursuant to 23 CAR § 117-107 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or the covered person’s authorized representative may file a request for an expedited external review pursuant to 23 CAR § 117-108; or

      1. (ii) If the final adverse determination concerns:

(b) (b) A denial of coverage based on a determination that the recommended or requested healthcare service or treatment is experimental or investigational, the covered person or the covered person’s authorized representative may file a request for a standard external review to be conducted pursuant to 23 CAR § 117-109 or if the covered person’s treating physician certifies in writing that the recommended or requested healthcare service or treatment that is the subject of the request would be significantly less effective if not promptly initiated, the covered person or the covered person’s authorized representative may request an expedited external review to be conducted under 23 CAR § 117-109.

1. (2) In addition to the information to be provided pursuant to subdivision (b)(1) of this section, 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 23 CAR § 117-116, highlighting the provisions in the external review procedures that give the covered person or the covered person’s authorized representative the opportunity to submit additional information and including any forms used to process an external review.
2. (3) As part of any forms provided under subdivision (b)(2) of this section, the health carrier shall include an authorization form, or other document approved by the commissioner that complies with the requirements of 45 C.F.R. § 164.508, by which the covered person, for purposes of conducting an external review under this part, authorizes the health carrier and the covered person’s treating healthcare provider to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review.