A member or member representative dissatisfied with the grievance decision rendered in the informal internal review process may seek a formal internal review before a reviewer, physician, or panel of physicians, advanced practice registered nurses, or other health care professionals selected by the insurer based upon the specific issues presented by the grievance.
Each request for a formal internal review shall be acknowledged by the insurer, in writing, to the member or member representative within ten (10) business days of receipt.
A reviewer physician or member of a panel selected by the insurer pursuant to § 6003.1 shall not have been involved in the grievance decision under review.
In all reviews requiring medical expertise, the reviewer or panel shall include at least one medical reviewer trained and certified, by a recognized specialty board listed in the current Directory of Medical Specialists, in the same specialty as the matter at issue.
Each medical reviewer shall be a physician or an advanced practice registered nurse or other health care provider possessing a nonrestricted license to practice or provide care anywhere in the United States and have no history of disciplinary action or sanctions pending or taken against them by any governmental or professional regulatory body.
Each formal internal review shall be concluded as soon as possible after receipt of all necessary documentation by the insurer, but in no event later than thirty (30) business days after the insurer has received notice of the request for a formal internal review, except as provided in § 6003.7.
If the formal internal review is from a decision regarding an emergency or urgent medical condition, the insurer shall complete the review within twenty-four (24) hours of the receipt of the request for a formal internal review.
An insurer shall determine within ten (10) business days of the filing of a request for a formal internal review whether the insurer has sufficient information to complete its review process. If the information is insufficient, the insurer shall:
The time within which an insurer must render a decision pursuant to this section may be extended only upon the written request of the member or member representative.
If a grievance decision by the insurer after a formal internal review is adverse to the member, the insurer shall provide the member or member representative with a written explanation of the decision and notification of the member's right to seek a formal external review of the decision.
The written notification required by § 6003.10 shall include:
If the insurer fails to comply with any deadline for completion of a formal internal review, the member or member representative shall be relieved of the duty to exhaust the formal internal review process, and may proceed directly to the external review process.
D.C. Mun. Regs. tit. 22, r. 22-B6003