Title 41, INSURANCE

41-5905. notice of right to external review. (1) When a final adverse benefit determination is made, the health carrier shall notify the covered person in writing of the covered person’s right to request an external review to be conducted pursuant to section 41-5908, 41-5909 or 4…

41-5906. request for external review. A covered person may make a request for an external review of a final adverse benefit determination. Except for a request for an expedited external review as set forth in section 41-5909, Idaho Code, all requests for external review shall be …

41-5907. Exhaustion of internal grievance process. (1) Except as provided in subsection (2) of this section, a request for an external review pursuant to section 41-5908, 41-5909 or 41-5910, Idaho Code, shall not be made until the covered person has exhausted the health carrier’s…

41-5908. standard external review. (1) Within four (4) months after the date of issuance of a notice of a final adverse benefit determination pursuant to section 41-5905, Idaho Code, a covered person may file a request for an external review with the director. The request shall b…

41-5909. expedited external review. (1) A covered person may make a request for an expedited external review of a pre-service or concurrent service adverse benefit determination where the requested service meets the definition of an urgent care request and the covered person has …

41-5910. binding nature of external review decision. (1) For a health care benefit plan not subject to the employee retirement income security act of 1974 (ERISA), the external review decision is final and binding on the health carrier and on the covered person. No judicial actio…

41-5911. approval of independent review organizations. (1) The director shall approve independent review organizations eligible to be assigned on a random basis to conduct external reviews under this chapter. (2) In order to be eligible for approval by the director under this sec…

41-5912. minimum qualifications for independent review organizations. (1) To be approved to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process an…

41-5913. 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 or oth…

41-5914. external review reporting requirements. (1) An independent review organization assigned pursuant to this chapter to conduct an external review shall maintain written records in the aggregate for Idaho by health carrier on all requests for external review for which it con…

41-5915. 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 reasonable cost of the independent review organization for conducting the external review.

41-5916. disclosure requirements. (1) Each health carrier shall include a summary 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 covered persons. The dis…

41-5917. SEVERABILITY. The provisions of this act are hereby declared to be severable and if any provision of this act or the application of such provision to any person or circumstance is declared invalid for any reason, such declaration shall not affect the validity of the rema…