Title 24, Insurance

PART I. GENERAL PROVISIONS §432E-1 Definitions. As used in this chapter, unless the context otherwise requires: "Adverse action" means an adverse determination or a final adverse determination. "Adverse determination" means a determination by a health carrier or its designated ut…

§432E-1.4 Medical necessity. (a) For contractual purposes, a health intervention shall be covered if it is an otherwise covered category of service, not specifically excluded, recommended by the treating licensed health care provider, and determined by the health plan's medical d…

§432E-1.5 Licensure of managed care plan medical directors. The medical director of any managed care plan providing services in the State shall hold an unlimited license to practice medicine or osteopathic medicine in the State pursuant to chapter 453. [L 1999, c 273, §1; am L 20…

§432E-10 Managed care plan performance measurement and data reporting standards. (a) It is the policy of this State that all managed care plans shall adopt and comply with nationally developed and promulgated standards for measuring quality, outcomes, access, satisfaction, and ut…

§432E-11 Accreditation of managed care plans. (a) Beginning January 1, 1999, the commissioner shall contract with one or more certified vendors of the consumer assessment health plan survey to conduct a survey of all managed care plans actively offering managed care plans in this…

[§432E-12] Rules. The commissioner shall adopt rules pursuant to chapter 91 necessary for the purposes of this chapter. [L 1999, c 137, pt of §2]

[§432E-13] Annual report. The commissioner shall submit annually to the legislature a report that shall contain the number of external review hearing cases reviewed, the type of cases reviewed, a summary of the nature of the cases reviewed, and the disposition of the cases review…

[§432E-2] Conflict with other laws. If there is a conflict with any other law, this chapter shall prevail to the extent that this chapter offers greater protection or rights to the enrollee. [L 1998, c 178, pt of §2]

[PART IV.] EXTERNAL REVIEW OF HEALTH INSURANCE DETERMINATIONS [§432E-31] Applicability and scope. (a) Except as provided in subsection (b), this part shall apply to all health carriers. (b) This part shall not apply to a policy or certificate that provides coverage only for a spe…

[§432E-32] Notice of right to external review. Notice of the right to external review issued pursuant to this part shall set forth the options available to the enrollee under this part. The commissioner may specify the form and content of notice of external review. [L 2011, c 230…

[§432E-33] Request for external review. (a) All requests for external review of a health carrier's adverse action shall be made in writing to the commissioner and shall include: The commissioner shall waive the filing fee required by this subsection if the commissioner determines…

§432E-34 Standard external review. (a) An enrollee or the enrollee's appointed representative may file a request for an external review with the commissioner within one hundred thirty days of receipt of notice of an adverse action. Within three business days after the receipt of …

§432E-35 Expedited external review. (a) Except as provided in subsection (i), an enrollee or the enrollee's appointed representative may request an expedited external review with the commissioner if the enrollee receives: (b) Upon receipt of a request for an expedited external re…

§432E-36 External review of experimental or investigational treatment adverse determinations. (a) An enrollee or an enrollee's appointed representative may file a request for an external review with the commissioner within one hundred thirty days of receipt of notice of an advers…

[§432E-37] Binding nature of external review decision. (a) An external review decision shall be binding on the health carrier and the enrollee except to the extent that the health carrier or the enrollee has other remedies available under applicable federal or state law. (b) An e…

[§432E-38] Approval of independent review organizations. (a) An independent review organization shall be approved by the commissioner in order to be eligible to be assigned to conduct external reviews under this part. (b) To be eligible for approval by the commissioner to conduct…

[§432E-39] Minimum qualifications for independent review organizations. (a) To be eligible for approval under this part to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the stan…

§432E-4 Enrollee participation in treatment decisions. (a) An enrollee shall have the right to be informed fully prior to making any decision about any treatment, benefit, or nontreatment. (b) In order to inform enrollees fully, the provider shall: (c) The provider shall discuss …

[§432E-40] Hold harmless for independent review organizations. No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent, or contractor of an independent review organization shall be liable in damages to …

[§432E-41] External review reporting requirements. (a) An independent review organization assigned pursuant to this part to conduct an external review shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it c…

[§432E-42] Funding of external review. The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the cost of the independent review organization for conducting the external review. There shall be no recourse again…

[§432E-43] Disclosure requirements. (a) Each health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to enrollees. (b) Disclosure sha…

[§432E-44] Rules. The insurance commissioner shall adopt rules pursuant to chapter 91 to effectuate the purpose of this part including requirements for forms to request external review and expedited external review, to request approval by independent review organizations, and for…

§432E-5 Complaints and appeals procedure for enrollees. (a) A health carrier with enrollees in this State shall establish and maintain a procedure to provide for the resolution of an enrollee's complaints and internal appeals. The procedure shall provide for expedited internal ap…

§432E-6.5 Expedited internal appeal, when authorized; standard for decision. (a) An enrollee may request that the internal appeal under section 432E-5 be conducted as an expedited appeal. If a request for expedited appeal is approved by the health carrier, the appropriate interna…

§432E-7 Information to enrollees. (a) The managed care plan shall provide to its enrollees upon enrollment and thereafter upon request the following information: This information shall be provided to prospective enrollees upon request. (b) Every managed care plan shall provide to…

[§432E-8] Enforcement. All remedies, penalties, and proceedings in articles 2 and 13 of chapter 431 made applicable hereby to managed care plans shall be invoked and enforced solely and exclusively by the commissioner. [L 1998, c 178, pt of §2]

PART III. REPORTING AND OTHER PROVISIONS [§432E-9] Utilization review. (a) Every managed care plan shall establish procedures for continuous review of quality of care, performance of providers, utilization of health services, facilities, and costs. (b) Notwithstanding any other p…