230 R.I. Code R. 230-RICR-20-30-14.7

Current through December 3, 2024

Section 230-RICR-20-30-14.7 - Internal Appeal and Reconsideration Requirements

A. All internal appeal and reconsideration requirements shall follow procedures in accordance with R.I. Gen. Laws § 27-18.9-7 and this Part.

B. All review agents shall conform and evidence to the Commissioner the following for the internal appeal of administrative and non-administrative (utilization review) adverse benefit determinations:

1. The review agent shall maintain and make available a written description of its appeal procedures by which the claimant may seek review of determinations not to authorize health care services.

2. The process established by each review agent shall include a reasonable time period within which an appeal must be filed to be considered and that time period shall not be less than one hundred eighty (180) calendar days after receipt of the adverse benefit determination notice.

3. During the appeal, a review agent may utilize a reconsideration process acceptable to the Commissioner in assessing an adverse benefit determination. A reconsideration process for utilization review benefit determinations must also comply with the requirements set forth in § 14.7(C) of this Part.

4. The review agent shall notify the claimant of the reconsideration or internal appeal determination consistent with the form and content requirements set forth in R.I. Gen. Laws § 27-18.9-6(b) and § 14.6(E) of this Part, as appropriate.

C. When a review agent adopts a policy to incorporate a process to perform a reconsideration to assess an adverse benefit determination, it must comply with the following:

1. Perform the reconsideration during the appeals process timelines; and

2. The reconsideration process shall be applied in a consistent non-arbitrary manner acceptable to the Commissioner.

D. Prior to a final internal appeal decision, the review agent must:

1. Inform the claimant of the opportunity to review the entire adverse determination and appeal file;

2. Inform the claimant of the opportunity to present evidence and/or additional information as part of the internal appeal process; and

3. Inform the claimant of, and allow the claimant, a reasonable period of time within the appeal notification timeframes to review the entire adverse determination and appeal file and/or to submit additional evidence or information.

E. Pursuant to R.I. Gen. Laws § 27-18.9-7(a)(5), a review agent is only entitled to request and review information or data relevant to the benefit determination and utilization review processes.

F. The review agent shall maintain records of written adverse benefit determinations, reversals of adverse benefit determinations occurring outside of the appeal process, reconsiderations, appeals and their resolution, and shall provide reports to the Office upon request and pursuant to § 14.9 of this Part.

G. For administrative appeals the review agent shall notify, in writing, the claimant of its decision:

1. As soon as practical considering circumstances;

2. In no case later than thirty (30) calendar days after receipt of the request for review of an adverse benefit determination for pre-service claims; and

3. In no case later than sixty (60) days after receipt of the request for review of an adverse benefit determination for post-service claims.

H. For utilization review appeals, the review agent shall notify, in writing, the claimant of its decision on the utilization review internal appeal:

1. As soon as practical considering medical circumstances; and

2. Within thirty (30) calendar days after receipt of the request for the review of an adverse benefit determination; or

3.. Within forty-five (45) calendar days after receipt of the request for the review of an adverse benefit determination only when the review agent documents that the claimant has requested an extension in order to submit additional information or the carrier substantiates and informs the claimant of the need to obtain additional information in order to make its appeal decision.

I. The review agent shall also provide for an expedited appeal process that takes into consideration medical exigencies according to the following:

1. Urgent and emergent status of a claim shall be determined by the ordering provider or the review agent, and a review agent must honor a determination of urgent or emergent status by an ordering provider; and

2. Adjudication of expedited appeals, including notification to the claimant of its decision on the appeal, not later than seventy-two (72) hours after receipt of the claimant's request for the appeal of an adverse benefit determination.

J. Pursuant to R.I. Gen. Laws § 27-18.9-7(a)(9), benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice and an opportunity for advance review. In addition, the review agent or health care entity shall be required to continue coverage pending the outcome of an appeal.

K. For a request for coverage of a drug that is not on the formulary, the review agent shall complete the internal appeal determination and notify the claimant of its determination according the following:

1. No later than seventy-two (72) hours following receipt of the appeal request; or

2. No later than twenty-four (24) hours following the receipt of the appeal request in cases where the beneficiary is suffering from a health condition that may seriously jeopardize the beneficiary's life, health, or ability to regain maximum function, with deference given to any such determination by the ordering provider, or when a beneficiary is undergoing a current course of treatment using a non-formulary drug; and

3. If approved on internal appeal, coverage of the non-formulary drug must be provided for the duration of the prescription, including refills unless expedited pursuant to § 14.7(J)(2) of this Part, in which case for the duration of the exigency.

L. Pursuant to R.I. Gen. Laws § 27-18.9-7(b)(1), a claimant is deemed to have exhausted the internal appeal process when the review agent conducting utilization review or health care entity fails to strictly adhere to all benefit determination and appeal processes with respect to a claim.

M. Peer reviewers under § 14.7 of this Part, who made the adverse benefit determination or reconsideration decisions for the case under appeal or who have participated in the direct care of the beneficiary, may not participate in reviewing the case under appeal.

N. Internal-level appeals decisions of utilization review determinations not to authorize a health care service that had been ordered by a physician, dentist, or other provider, shall be not be made until the review agent's peer reviewer with the same licensure status as typically manages the condition, procedure, treatment, or requested service under discussion has spoken to, or conducted, an equivalent two-way, direct communication with the beneficiary's attending physician, dentist, other professional provider, or other qualified professional provider responsible for the treatment of the beneficiary concerning the services under review.

O. When a utilization review adverse determination is made on internal appeal or reconsideration, including determinations with regard to whether a particular service, treatment, drug, or other item is experimental, investigational or not medically necessary or appropriate, the review agent must adhere to the following:

1. All adverse reconsideration decisions must be made by a peer reviewer;

2. The peer reviewer making the appeal decision shall be an individual in the same or similar specialty as typically manages the condition;

3. The review agent must provide the qualifications of the peer reviewer(s) to the claimant upon request; and

4. The review agency's peer reviewers making the reconsideration and internal appeal decisions must document and sign their decisions.

P. The review agent conducting utilization review must ensure that the appropriate peer reviewer making the internal appeal decision is reasonably available to review the case and must conform to the following:

1. Each peer reviewer shall have access to and review all necessary information requested by the agency and/or submitted by the provider(s) and/or claimant; and

2. Each agency shall provide accurate peer reviewer contact information to the ordering provider if requested during the utilization review process and upon making an adverse benefit determination. In order to ensure direct communication, this contact information must provide a mechanism for direct communication with the peer reviewer.

3. Peer reviewers making an internal appeal decision shall respond to and reasonably accommodate a provider's request for the equivalent two-way, direct communication required by law prior to the internal level of appeal decision, as well as any additional provider request for a two-way direct communication with a peer reviewer in accordance with R.I. Gen. Laws §§ 27-18.9-7(b)(4) and 27-18.9-7(b)(5) and this Part.

a. A review agent will have met the requirements of § 14.7(P)(3) of this Part above, when it has made two reasonable attempts to contact the attending provider.

b. Repeated violations of this section shall be deemed to be substantial violations pursuant to R.I. Gen. Laws §§ 27-18.9-13 and 27-18.9-14 and shall be cause for the imposition of penalties under these sections.

230 R.I. Code R. 230-RICR-20-30-14.7

Adopted effective 6/9/2019