Section 3 AAC 28.952 - Notice of right to external review(a) A health care insurer shall notify a covered person or the covered person's authorized representative in writing of the covered person's right to request an external review under 3 AAC 28.958 - 3 AAC 28.962. A health care insurer shall provide the notice of the right to request an external review when the health care insurer sends written notice of (1) an adverse determination upon completion of the health care insurer's utilization review process under 3 AAC 28.900 - 3 AAC 28.918; and(2) a final adverse determination.(b) The notice under (a) of this section must include the following, or .substantially equivalent, language; "We have denied your request for the provision of, or payment for, a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care .setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for external review to the director of the Alaska Division of insurance by mail or personal delivery at the Alaska Division of Insurance, 550 West 7th Avenue, Anchorage, AK. 99501-3567, by electronic mail to insurance@alaska.gov, or by facsimile transmission by calling (907) 269-7910."
(c) A notice under (a) of this section relating to an adverse determination must include a statement informing a covered person or the covered person's authorized representative that if the covered person has a medical condition where the time frame for completion of an expedited review of a grievance involving an adverse determination under 3 AAC 28.938 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 (1) file a request for an expedited external review under 3 AAC 28.960, or under 3 AAC 28.962 if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated; and at the same time that a covered person or the covered person's authorized representative files a request for an expedited review of a grievance involving an adverse determination under 3 AAC 28.938, the independent review organization assigned to conduct the expedited external review shall determine whether the covered person or the covered person's authorized representative shall be required to complete the expedited review of the grievance before the independent review organization conducts the expedited external review; and(2) file a grievance under the health care insurer's internal grievance process under 3 AAC 2S.936; however, the covered person or the covered person's authorized representative may file a request for external review under 3 AAC 28.954 and will be considered to have exhausted the health care insurer's internal grievance process for purposes of 3 AAC 28.956 if (A) the health care insurer has not issued a written decision to the covered person or the covered person's authorized representative not later than 30 days after the date the covered person or the covered person's authorized representative files the grievance with the health care insurer; and(B) the covered person or the covered person's authorized representative has not requested or agreed to a delay.(d) A notice under (a) of this section relating to a final adverse determination must include a statement informing a covered person or the covered person's authorized representative that the covered person or die covered person's authorized representative may request (1) an expedited external review under 3 AAC 28.960 if(A) the covered person has a medical condition where the time frame for completion of a standard external review under 3 AAC 28.958 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function;(B) the final adverse determination concerns an admission, availability of care, continued stay, or health care .service for which the covered person received emergency services, but has not been discharged from a facility;(2) a standard external review under 3 AAC 28.962 if a denial of coverage was based on a determination that the recommended or requested health care service or treatment is experimental or investigational; or(3) an expedited external review under 3 AAC 28.962 if (A) a denial of coverage was based on a determination that the recommended or requested health care service or treatment is experimental or investigational; and(B) the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated.(e) A health care insurer shall include with a notice under (a) of this section a copy of the description of the standard and expedited external review procedures the health care insurer is required to provide under 3 AAC 28.982; the description must (1) highlight 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(2) include the forms that the health care insurer uses to process an external review.(f) A health care insurer shall include with the notice under (a) of this section a release form, or other document approved by the director that complies with the requirements of 45 C.F.R. 164.508, by which the covered person or the covered person's authorized representative authorizes the health care insurer and the covered person's treating health care provider to disclose protected health information, including medical records concerning the covered person that are pertinent to the external review. Eff. 3/15/2018,Register 225, April 2018Authority:AS 21.06.090
AS 21.07.005