Section 2164.1. External review applicability and scope.
(a) Applicability.--The external review provisions of this subdivision shall apply to:
(1) An adverse benefit determination rendered by an insurer that are based on any of the following:
(i) Medical necessity.
(ii) Appropriateness of service.
(iii) Health care setting.
(iv) Level of care.
(v) Effectiveness of a covered benefit.
(2) Disputes regarding an insurer's compliance with the surprise billing and cost-sharing protections under sections 2799a-1 and 2799a-2 of the Public Health Service Act (58 Stat. 682, 42 U.S.C. § 300gg-19) and regulations promulgated thereunder.
(b) Nonapplicability.--The external review provisions of this subdivision do not apply to:
(1) Complaints, which may be appealed under section 2142.
(2) Grievances, which may be reviewed under section 2162.
(3) Administrative denials, which may be appealed under section 2142.
(c) No minimum threshold.--The external review process is available to a covered person or covered person's authorized representative with respect to health care services of any monetary value. There is no minimum financial threshold for filing a request for external review.
(2164.1 added Nov. 3, 2022, P.L.2068, No.146)