(a) (1) Notice of an adverse determination shall be provided to the healthcare provider that initiated the prior authorization.(2) Notice may be made by electronic mail, fax, or hard copy letter sent by regular mail, or verbally, as requested by the subscriber's healthcare provider.
(1) Notice of an adverse determination shall be provided to the healthcare provider that initiated the prior authorization.
(2) Notice may be made by electronic mail, fax, or hard copy letter sent by regular mail, or verbally, as requested by the subscriber's healthcare provider.
(b) The written or verbal notice to a healthcare provider under this section shall include:(1) The following information:(A) The telephone number of the physician responsible for making the adverse determination and, in the event that the physician responsible for making the adverse determination is not available, a telephone number where a peer-to-peer contact with another physician regarding the adverse determination can be made;(B) The reviewing physician's specialty or practice area, including board certification status or board eligibility;(C) A list of states in which the reviewing physician is licensed;(D) For a verbal notice, the name and license number of the reviewing physician; and(E) For a written notice, a telephone number that the requesting healthcare provider may call to obtain the name and license number of the reviewing physician;(2) The written clinical criteria, if any, and any internal rule, guideline, or protocol on which the utilization review entity relied when making the adverse determination and how those provisions apply to the subscriber's specific medical circumstance;(3) Information that describes the procedure through which the healthcare provider may request a copy of any report developed by personnel performing the review that led to the adverse determination; and(4) (A) Information that explains the right to appeal the adverse determination.(B) The information required under subdivision (b)(4)(A) of this section shall include:(i) Instructions concerning how to perfect an appeal and how the healthcare provider may ensure that written materials supporting the appeal will be considered in the appeal process; and(ii) (a) Addresses and telephone numbers to be used by healthcare providers to make complaints to the State Insurance Department.(b) Subdivision (b)(4)(B)(ii)(a) of this section does not apply to self-insured plans for employees of governmental entities.
(1) The following information:(A) The telephone number of the physician responsible for making the adverse determination and, in the event that the physician responsible for making the adverse determination is not available, a telephone number where a peer-to-peer contact with another physician regarding the adverse determination can be made;(B) The reviewing physician's specialty or practice area, including board certification status or board eligibility;(C) A list of states in which the reviewing physician is licensed;(D) For a verbal notice, the name and license number of the reviewing physician; and(E) For a written notice, a telephone number that the requesting healthcare provider may call to obtain the name and license number of the reviewing physician;
(A) The telephone number of the physician responsible for making the adverse determination and, in the event that the physician responsible for making the adverse determination is not available, a telephone number where a peer-to-peer contact with another physician regarding the adverse determination can be made;
(B) The reviewing physician's specialty or practice area, including board certification status or board eligibility;
(C) A list of states in which the reviewing physician is licensed;
(D) For a verbal notice, the name and license number of the reviewing physician; and
(E) For a written notice, a telephone number that the requesting healthcare provider may call to obtain the name and license number of the reviewing physician;
(2) The written clinical criteria, if any, and any internal rule, guideline, or protocol on which the utilization review entity relied when making the adverse determination and how those provisions apply to the subscriber's specific medical circumstance;
(3) Information that describes the procedure through which the healthcare provider may request a copy of any report developed by personnel performing the review that led to the adverse determination; and
(4) (A) Information that explains the right to appeal the adverse determination.(B) The information required under subdivision (b)(4)(A) of this section shall include:(i) Instructions concerning how to perfect an appeal and how the healthcare provider may ensure that written materials supporting the appeal will be considered in the appeal process; and(ii) (a) Addresses and telephone numbers to be used by healthcare providers to make complaints to the State Insurance Department.(b) Subdivision (b)(4)(B)(ii)(a) of this section does not apply to self-insured plans for employees of governmental entities.
(A) Information that explains the right to appeal the adverse determination.
(B) The information required under subdivision (b)(4)(A) of this section shall include:(i) Instructions concerning how to perfect an appeal and how the healthcare provider may ensure that written materials supporting the appeal will be considered in the appeal process; and(ii) (a) Addresses and telephone numbers to be used by healthcare providers to make complaints to the State Insurance Department.(b) Subdivision (b)(4)(B)(ii)(a) of this section does not apply to self-insured plans for employees of governmental entities.
(i) Instructions concerning how to perfect an appeal and how the healthcare provider may ensure that written materials supporting the appeal will be considered in the appeal process; and
(ii) (a) Addresses and telephone numbers to be used by healthcare providers to make complaints to the State Insurance Department.(b) Subdivision (b)(4)(B)(ii)(a) of this section does not apply to self-insured plans for employees of governmental entities.
(a) Addresses and telephone numbers to be used by healthcare providers to make complaints to the State Insurance Department.
(b) Subdivision (b)(4)(B)(ii)(a) of this section does not apply to self-insured plans for employees of governmental entities.
(c) (1) When a healthcare service for the treatment or diagnosis of any medical condition is restricted or denied in favor of a fail first protocol preferred by the utilization review entity, the subscriber's healthcare provider shall have access to a clear and convenient process to expeditiously request an override of that restriction or denial from the utilization review entity or healthcare insurer.(2) Upon request, the subscriber's healthcare provider shall be provided contact information, including a phone number, for a person to initiate the request for an expeditious override of the restriction or denial.
(1) When a healthcare service for the treatment or diagnosis of any medical condition is restricted or denied in favor of a fail first protocol preferred by the utilization review entity, the subscriber's healthcare provider shall have access to a clear and convenient process to expeditiously request an override of that restriction or denial from the utilization review entity or healthcare insurer.
(2) Upon request, the subscriber's healthcare provider shall be provided contact information, including a phone number, for a person to initiate the request for an expeditious override of the restriction or denial.
(d) The appeal process described in subdivision (b)(4) of this section shall not apply when a healthcare service is denied because the healthcare service is within a category of healthcare services not covered by the health benefit plan.
(e) (1) Upon an adverse determination by a utilization review entity, the utilization review entity shall provide a written notice to the subscriber, which shall include without limitation:(A) (i) An explanation in clear and ordinary terms of the basis for the adverse determination.(ii) An explanation under subdivision (e)(1)(A)(i) of this section shall include without limitation:(a) A listing of clinical criteria, if applicable, and any internal rule, guideline, or protocol upon which a utilization review entity relied when making an adverse determination; and(b) The reason why the provisions listed in subdivision (e)(1)(A)(ii)(a) of this section apply to the subscriber's specific medical circumstance;(B) A description of the procedure through which the subscriber may request a copy of a report developed by personnel performing the utilization review that led to the adverse determination;(C) Information that explains to the subscriber the right to appeal the adverse determination, including instructions concerning how to perfect an appeal and how the subscriber may ensure that written materials supporting the appeal will be considered in the appeals process; and(D) An address and telephone number to be used by a subscriber to make a complaint to the Arkansas State Medical Board, the State Board of Health, and the State Insurance Department.(2) A utilization review entity shall treat a subscriber's request for any information related to a prior authorization, including a general inquiry, as a request under subdivision (e)(1) of this section.
(1) Upon an adverse determination by a utilization review entity, the utilization review entity shall provide a written notice to the subscriber, which shall include without limitation:(A) (i) An explanation in clear and ordinary terms of the basis for the adverse determination.(ii) An explanation under subdivision (e)(1)(A)(i) of this section shall include without limitation:(a) A listing of clinical criteria, if applicable, and any internal rule, guideline, or protocol upon which a utilization review entity relied when making an adverse determination; and(b) The reason why the provisions listed in subdivision (e)(1)(A)(ii)(a) of this section apply to the subscriber's specific medical circumstance;(B) A description of the procedure through which the subscriber may request a copy of a report developed by personnel performing the utilization review that led to the adverse determination;(C) Information that explains to the subscriber the right to appeal the adverse determination, including instructions concerning how to perfect an appeal and how the subscriber may ensure that written materials supporting the appeal will be considered in the appeals process; and(D) An address and telephone number to be used by a subscriber to make a complaint to the Arkansas State Medical Board, the State Board of Health, and the State Insurance Department.
(A) (i) An explanation in clear and ordinary terms of the basis for the adverse determination.(ii) An explanation under subdivision (e)(1)(A)(i) of this section shall include without limitation:(a) A listing of clinical criteria, if applicable, and any internal rule, guideline, or protocol upon which a utilization review entity relied when making an adverse determination; and(b) The reason why the provisions listed in subdivision (e)(1)(A)(ii)(a) of this section apply to the subscriber's specific medical circumstance;
(i) An explanation in clear and ordinary terms of the basis for the adverse determination.
(ii) An explanation under subdivision (e)(1)(A)(i) of this section shall include without limitation:(a) A listing of clinical criteria, if applicable, and any internal rule, guideline, or protocol upon which a utilization review entity relied when making an adverse determination; and(b) The reason why the provisions listed in subdivision (e)(1)(A)(ii)(a) of this section apply to the subscriber's specific medical circumstance;
(a) A listing of clinical criteria, if applicable, and any internal rule, guideline, or protocol upon which a utilization review entity relied when making an adverse determination; and
(b) The reason why the provisions listed in subdivision (e)(1)(A)(ii)(a) of this section apply to the subscriber's specific medical circumstance;
(B) A description of the procedure through which the subscriber may request a copy of a report developed by personnel performing the utilization review that led to the adverse determination;
(C) Information that explains to the subscriber the right to appeal the adverse determination, including instructions concerning how to perfect an appeal and how the subscriber may ensure that written materials supporting the appeal will be considered in the appeals process; and
(D) An address and telephone number to be used by a subscriber to make a complaint to the Arkansas State Medical Board, the State Board of Health, and the State Insurance Department.
(2) A utilization review entity shall treat a subscriber's request for any information related to a prior authorization, including a general inquiry, as a request under subdivision (e)(1) of this section.