230 R.I. Code R. 230-RICR-20-30-14.8

Current through December 3, 2024

Section 230-RICR-20-30-14.8 - External Appeal of Non-Administrative Benefit Determinations Requirements

A. In the cases where the utilization review adverse benefit determination or the final internal level of appeal to reverse a utilization review adverse benefit determination is unsuccessful, the health care entity or review agent shall provide for an external appeal by an independent review organization (IRO) approved by the Commissioner and ensure that the external appeal complies with all applicable laws, regulations, and the Office's instructions.

B. In order to seek an external appeal;

1. The claimant must have exhausted the internal appeal process; and

2. The claimant is deemed to have exhausted the internal appeal process when the review agent or health care entity fails to strictly adhere to all benefit determination and appeal processes with respect to a claim; or

3. The claimant has applied for expedited external review at the same time as applying for expedited internal review.

C. R.I. Gen. Laws § 27-18.9-8(a)(3), a claimant shall have at least four (4) months after receipt of a notice of the decision on a final internal appeal to request an external appeal by an IRO.

D. Health care entities and review agent must use a rotational IRO registry process specified by the Commissioner.

E. Pursuant to R.I. Gen. Laws § 27-18.9-8(a)(5), a claimant requesting an external appeal may be charged no more than a twenty-five dollar ($25.00) external appeal fee by the review agent. The external appeal fee, if charged, must be refunded to the claimant if the adverse benefit determination is reversed through external review. The external appeal fee must be waived if payment of the fee would impose an undue financial hardship on the beneficiary. In addition, the annual limit on external appeal fees for any beneficiary within a single plan year (in the individual market, within a policy year) must not exceed seventy-five dollars ($75.00).

F. A claimant requesting an external appeal of an excepted benefit as defined in 42 U.S.C. § 300gg-91(c), may be charged no more than a one-hundred dollars ($100.00) external appeal fee by the review agent. The external appeal fee, if charged, must be refunded to the claimant if the adverse benefit determination is reversed through external review. The external appeal fee must be waived if payment of the fee would impose an undue financial hardship on the beneficiary.

In addition, the annual limit on external appeal fees for any beneficiary within a single plan year (in the individual market, within a policy year) must not exceed three-hundred dollars ($300.00).

G. Pursuant to R.I. Gen. Laws § 27-18.9-8(a)(6), the IRO and/or the review agent and/or the health care entity may not impose a minimum dollar amount of a claim for a claim to be eligible for external review by an IRO.

H. Pursuant to R.I. Gen. Laws § 27-18.9-8(a)(7), the decision of the external appeal by the IRO shall be binding on the health care entity and/or review agent; however, any person who is aggrieved by a final decision of the external appeal agency is entitled to judicial review in a court of competent jurisdiction.

I. Pursuant to R.I. Gen. Laws § 27-18.9-8(a)(8), the health care entity must provide benefits (including making payment on the claim) pursuant to an external review decision without delay.

J. Pursuant to R.I. Gen. Laws § 27-18.9-8(a)(9), the Commissioner shall determine the process and criteria for designation, operation, policy, oversight, and termination of designation as an IRO. The IRO shall not be required to be certified under the Act or these regulations for activities conducted pursuant to its designation.

K. The health care entity and the review agent must ensure that the external appeal process shall include, but not be limited to, the following characteristics:

1. Within at least five (5) business days of the request for an external appeal, a notice must be received by the claimant that their request has been forwarded to the independent review organization (IRO). The notice shall include a description of the process for the claimant to submit additional information to the IRO within five (5) business days of receipt of this notification.

2. Pursuant to R.I. Gen. Laws § 27-18.9-8(b)(2), the IRO must notice the claimant of its external appeal decision to uphold or overturn the review agency decision:

a. No more than ten (10) calendar days from receipt of all the information necessary to complete the external review and no more than forty-five (45) calendar days after the receipt of the request for external review; and

b. In the event of an expedited external appeal by the IRO for urgent or emergent health care services, as expeditiously as possible considering exigencies and no more than seventy-two (72) hours after the receipt of the request for the external appeal by the IRO.

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

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

2. The external appeal reviewer making the external appeal decision shall be appropriately trained having the same licensure status as the ordering provider or be a physician or dentist as appropriate;

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

4. The IRO must provide the qualifications of the external appeal reviewer(s) to the claimant upon request; and

5. The external appeal reviewers making the external appeal decisions must document and sign their decisions.

M. For an external appeal of an internal appeal decision of a non-formulary drug, the health care entity and the review agent must ensure that the IRO completes the external appeal determination and notifies the claimant of its determination:

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

2. If the original request or appeal was an expedited request, as soon as possible taking into account exigencies and no later than twenty-four (24) hours following the receipt of the external appeal request; and

3. If approved on external appeal, coverage of the non-formulary drug must be provided for the duration of the prescription, including refills, unless expedited then for the duration of the exigencies.

N. A health care entity and review agent must ensure that the IRO adheres to the external appeal decision notifications in accordance with R.I. Gen. Laws § 27-18.9-8(c) and this Part.

230 R.I. Code R. 230-RICR-20-30-14.8

Adopted effective 6/9/2019