(a) Except as provided in subsection (f) of this section, a covered person or the covered person’s authorized representative may make a request for an expedited external review with the Insurance Commissioner at the time the covered person receives:

1. (1) An adverse determination if the:

   1. (A) Adverse determination involves a medical condition of the covered person for which the timeframe for completion of an expedited internal 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; and
   2. (B) Covered person or the covered person’s authorized representative has filed 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; or

2. (2) A final adverse determination if the:

   1. (A) 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; or
   2. (B) Final adverse determination concerns an admission, availability of care, continued stay, or healthcare service for which the covered person received emergency services, but has not been discharged from a facility.

(b)

1. (1) Upon receipt of a request for an expedited external review, the commissioner immediately shall send a copy of the request to the health carrier.

2. (2)

   1. (A) Immediately upon receipt of the request pursuant to subdivision (b)(1) of this section, the health carrier shall determine whether the request meets the reviewability requirements set forth in 23 CAR § 117-107(b).
   2. (B) The health carrier shall immediately notify the commissioner, the covered person, and, if applicable, the covered person’s authorized representative of its eligibility determination.

3. (3)

   1. (A) The commissioner may specify the form for the health carrier’s notice of initial determination under this subsection and any supporting information to be included in the notice by bulletin, directive, or other publication to health carriers.
   2. (B) The notice of initial determination shall include a statement informing the covered person and, if applicable, the covered person’s authorized representative that a health carrier’s initial determination that an external review request is ineligible for review may be appealed to the commissioner.

4. (4)

   1. (A) The commissioner may determine that a request is eligible for external review notwithstanding a health carrier’s initial determination that the request is ineligible and require that it be referred for external review.
   2. (B) In making a determination under subdivision (b)(4)(A) of this section, the commissioner’s decision shall be:

(i) Made in accordance with the terms of the covered person’s health benefit plan; and

1. (ii) Subject to all applicable provisions of this part.

2. (5)

   1. (A) Upon receipt of the notice that the request meets the reviewability requirements, the commissioner immediately shall assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations compiled and maintained by the commissioner pursuant to 23 CAR § 117-111.
   2. (B) The commissioner shall immediately notify the health carrier of the name of the assigned independent review organization.

3. (6) In reaching a decision in accordance with subsection (e) of this section, the assigned independent review organization is not bound by any decisions or conclusions reached during the health carrier’s:

   1. (A) Utilization review process; or

   2. (B) Internal appeal process.

      1. (c) Upon receipt of the notice from the commissioner of the name of the independent review organization assigned to conduct the expedited external review pursuant to subdivision (b)(5) of this section, the health carrier or its designee utilization review organization shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization:
4. (1) Electronically;
5. (2) By telephone or facsimile; or

6. (3) By any other available expeditious method.

   1. (d) In addition to the documents and information provided or transmitted pursuant to subsection (c) of this section, the assigned independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision:
7. (1) The covered person’s pertinent medical records;
8. (2) The attending healthcare professional’s recommendation;

9. (3) Consulting reports from appropriate healthcare professionals and other documents submitted by the:

   1. (A) Health carrier;
   2. (B) Covered person;
   3. (C) Covered person’s authorized representative; or
   4. (D) Covered person’s treating provider;
10. (4) The terms of coverage under the covered person’s health benefit plan with the health carrier to ensure that the independent review organization’s decision is not contrary to the terms of coverage under the covered person’s health benefit plan with the health carrier;

11. (5) The most appropriate practice guidelines, which:

    1. (A) Shall include evidence-based standards; and

    2. (B) May include any other practice guidelines developed by:

       1. (i) The United States Government; or
       2. (ii) National or professional medical societies, boards, and associations;
12. (6) Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review organization in making adverse determinations; and

13. (7) The opinion of the independent review organization’s clinical reviewer or reviewers after considering subdivisions (d)(1) – (6) of this section to the extent the:

    1. (A) Information and documents are available; and
    2. (B) Clinical reviewer or reviewers consider appropriate.

(e)

1. (1) As expeditiously as the covered person’s medical condition or circumstances requires, but in no event more than seventy-two (72) hours after the date of receipt of the request for an expedited external review that meets the reviewability requirements set forth in 23 CAR § 117-107(b), the assigned independent review organization shall:

   1. (A) Make a decision to uphold or reverse the adverse determination or final adverse determination; and
   2. (B) Notify the covered person, if applicable, the covered person’s authorized representative, the health carrier, and the commissioner of the decision.

2. (2) If the notice provided pursuant to subdivision (e)(1) of this section was not in writing, within forty-eight (48) hours after the date of providing that notice, the assigned independent review organization shall:

   1. (A) Provide written confirmation of the decision to:

      1. (i) The covered person;
      2. (ii) If applicable, the covered person’s authorized representative;
      3. (iii) The health carrier; and
      4. (iv) The commissioner; and
   2. (B) Include the information set forth in 23 CAR § 117-107(i)(2).
3. (3) Upon receipt of the notice of a decision pursuant to subdivision (e)(1) of this section reversing the adverse determination or final adverse determination, the health carrier immediately shall approve the coverage that was the subject of the adverse determination or final adverse determination.

(g) The assignment by the commissioner of an approved independent review organization to conduct an external review in accordance with this section shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on:

1. (1) The nature of the healthcare service that is the subject of the adverse determination or final adverse determination; and
2. (2) Other circumstances, including conflict of interest concerns pursuant to 23 CAR § 117-112(d).