3 Alaska Admin. Code § 28.956

Current through October 17, 2024

Section 3 AAC 28.956 - Exhaustion of internal grievance process

(a) Except as otherwise provided under this section, before making a request for an external review, a covered person or the covered person's authorized representative must exhaust a health care insurer's internal grievance process under 3 AAC 28.930 - 3 AAC 28.938.

(b) A covered person or the covered person's authorized representative will be considered to have exhausted a health care insurer's grievance process if the covered person or the covered person's authorized representative

(1) has filed a grievance involving an adverse determination; and

(2) except to the extent the covered person or the covered person's authorized representative requested or agreed to a delay, has not received a written decision on the grievance from the health care insurer not later than 30 days after the covered person or the covered person's authorized representative filed the grievance with the health care insurer.

(c) Notwithstanding (b) of this section, a covered person or the covered person's authorized representative must exhaust a health care insurer's internal grievance process before making a request for an external review of an adverse determination involving a retrospective review determination made under 3 AAC 28.900 - 3 AAC 28.918.

(d) When 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 covered person or the covered person's authorized representative may file a request for an expedited external review of an adverse determination without exhausting a health care insurer's internal grievance process if

(1) under 3 AAC 28.960, the covered person has a medical condition where the time frame for completion of an internal review of the grievance involving an adverse determination under 3 AAC 28.938 would

(A) seriously jeopardize the life or health of the covered person; or

(B) jeopardize the covered person's ability to regain maximum function; or

(2) under 3 AAC 28.962, 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.

(e) Before conducting an expedited external review, an independent review organization shall determine whether the covered person is first required to complete the expedited grievance review process under 3 AAC 28.938. Upon determining that the covered person has not exhausted internal grievance processes, the independent review organization shall immediately notify the covered person or the covered person's authorized representative of its determination and that (he independent review organization will not proceed with the expedited external review

(1) until completion of the expedited grievance review process; and

(2) while the covered person's grievance at the completion of the expedited grievance review process remains unresolved,

(f) A covered person or the covered person's authorized representative may request an external review of an adverse determination before the covered person or the covered person's authorized representative has exhausted a health care insurer's internal grievance procedures if the health care insurer agrees to waive the exhaustion requirement. If the requirement to exhaust the health care insurer's internal grievance procedures is waived, the covered person or the covered person's authorized representative may file a written request with the director for a standard external review.

3 AAC 28.956

Eff. 3/15/2018,Register 225, April 2018

Authority:AS 21.06.090

AS 21.07.005