D.C. Mun. Regs. tit. 22, r. 22-B6004

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 22-B6004 - EXPEDITED REVIEW PROCESS IN EMERGENCY OR URGENT MEDICAL CONDITION CASES

6004.1

An expedited review is required for an adverse decision involving an emergency or urgent medical condition in accordance with this section if:

(a) The adverse decision is rendered for health care services that are proposed but have not been delivered; and

(b) The services are necessary to treat a condition or illness that, without prompt or immediate medical attention, would place the health of the individual in serious jeopardy, result in serious impairment to bodily functions, result in serious dysfunction of any bodily organ or jeopardize the life or health of the member or the member's ability to regain maximum function, or cause the member to be a danger to self or others.

6004.2

In emergency or urgent medical condition cases, the insurer shall send notice in writing of any adverse decision to the member or the member representative within one (1) business day after a decision has been orally communicated to the member or member representative.

6004.3

An insurer shall render a final grievance decision in an emergency or urgent medical condition case within twenty-four (24) hours after the grievance was filed pursuant to the insurer's internal grievance process.

6004.4

The content of any written notice by an insurer of an adverse grievance decision under these rules shall comply with § 6001.4 of this Chapter.

6004.5

In emergency or urgent medical condition cases, a request for an external review may be filed with the Director if a grievance decision reached in an informal or formal internal review is not rendered within twenty-four (24) hours after the filing of the grievance pursuant to the insurer's internal grievance process.

6004.6

After external review of a grievance by an independent review organization ("IRO") in an emergency or urgent medical condition case, the Director shall send written notice to all parties of the IRO's recommendations within twenty-four (24) hours after the Director or the Director's designee has informed the member or member representative and the insurer of the recommendation through an oral communication.

D.C. Mun. Regs. tit. 22, r. 22-B6004

Final Rulemaking published at 47 DCR 229 (January 14, 2000)