| (a) Appeal of prospective or concurrent review adverse
determinations. Each URA must comply with its written procedures for
appeals. The written procedures for appeals must comply with Insurance
Code Chapter 4201, Subchapter H, concerning Appeal of Adverse Determination,
and must include provisions that specify the following:
(1) timeframes for filing the written or oral appeal,
which may not be less than 30 calendar days after the date of issuance
of written notification of an adverse determination;
(2) an enrollee, an individual acting on behalf of
the enrollee, or the provider of record may appeal the adverse determination
orally or in writing;
(3) an appeal acknowledgement letter must:
(A) be sent to the appealing party within five working
days from receipt of the appeal;
(B) acknowledge the date the URA received the appeal;
(C) include a list of relevant documents that must
be submitted by the appealing party to the URA; and
(D) include a one-page appeal form to be filled out
by the appealing party when the URA receives an oral appeal of an
adverse determination.
(4) Appeal decisions must be made by a physician who
has not previously reviewed the case.
(5) In any instance in which the URA is questioning
the medical necessity or appropriateness, or the experimental or investigational
nature, of the health care services prior to issuance of an adverse
determination, the URA must afford the provider of record a reasonable
opportunity to discuss the plan of treatment for the enrollee with
a physician. The provision must require that the discussion include,
at a minimum, the clinical basis for the URA's decision.
(6) If an appeal is denied and, within 10 working days
from the denial, the health care provider sets forth in writing good
cause for having a particular type of specialty provider review the
case, the denial must be reviewed by a health care provider in the
same or similar specialty that typically manages the medical, dental,
or specialty condition, procedure, or treatment under discussion for
review of the adverse determination. The specialty review must be
completed within 15 working days of receipt of the request. The provision
must state that notification of the appeal under this paragraph must
be in writing.
(7) In addition to the written appeal, a method for
expedited appeals for emergency care denials, denials of care for
life-threatening conditions, and denials of continued stays for hospitalized
enrollees is available. The provision must state that:
(A) the procedure must include a review by a health
care provider who has not previously reviewed the case and who is
of the same or a similar specialty as the health care provider that
typically manages the medical condition, procedure, or treatment under
review;
(B) an expedited appeal must be completed based on
the immediacy of the medical or dental condition, procedure, or treatment,
but may in no event exceed one working day from the date all information
necessary to complete the appeal is received; and
(C) an expedited appeal determination may be provided
by telephone or electronic transmission, but must be followed with
a letter within three working days of the initial telephonic or electronic
notification;
(8) After the URA has sought review of the appeal of
the adverse determination, the URA must issue a response letter to
the enrollee or an individual acting on behalf of the enrollee, and
the provider of record, explaining the resolution of the appeal. The
provision must state that the letter must include:
(A) a statement of the specific medical, dental, or
contractual reasons for the resolution;
(B) the clinical basis for the decision;
(C) a description of or the source of the screening
criteria that were utilized in making the determination;
(D) the professional specialty of the physician who
made the determination;
(E) notice of the appealing party's right to seek review
of the adverse determination by an IRO under §19.1717 of this
title (relating to Independent Review of Adverse Determinations);
(F) notice of the independent review process;
(G) a copy of a request for a review by an IRO form;
and
(H) procedures for filing a complaint as described
in §19.1705(f) of this title (relating to General Standards of
Utilization Review).
(9) A statement that the appeal must be resolved as
soon as practical, but, under Insurance Code §4201.359 and §1352.006,
in no case later than 30 calendar days after the date the URA receives
the appeal from the appealing party referenced under paragraph (3)
of this subsection.
(10) In a circumstance involving an enrollee's life-threatening
condition, the enrollee is entitled to an immediate appeal to an IRO
and is not required to comply with procedures for an appeal of the
URA's adverse determination.
(b) Appeal of retrospective review adverse determinations.
A URA must maintain and make available a written description of the
appeal procedures involving an adverse determination in a retrospective
review. The written procedures for appeals must specify that an enrollee,
an individual acting on behalf of the enrollee, or the provider of
record may appeal the adverse determination orally or in writing.
The appeal procedures must comply with:
(1) Chapter 21, Subchapter T, of this title (relating
to Submission of Clean Claims), if applicable;
(2) Section 19.1709 of this title (relating to Notice
of Determinations Made in Utilization Review), for retrospective utilization
review adverse determination appeals; and
(3) Insurance Code §4201.359.
(c) Appeals concerning an acquired brain injury. A
URA must comply with this subsection in regard to a determination
concerning an acquired brain injury as defined by §21.3102 of
this title (relating to Definitions). Not later than three business
days after the date on which an individual requests utilization review
or requests an extension of coverage based on medical necessity or
appropriateness, a URA must provide notification of the determination
through a direct telephone contact to the individual making the request.
This subsection does not apply to a determination made for coverage
under a small employer health benefit plan.
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