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External Review of HMO Decisions
This legislation, effective July 1, 1999
- Establishes a prompt, consistent and fair external review process for all health care services
denied on the grounds that the service is not medically necessary;
- Establishes an external review process for patients with life-threatening or disabling conditions
seeking clinical trials, off-label use of drugs and experimental or investigational procedures
or treatments when such services are denied upon the basis that they are experimental or investigational;
- Requires insurers to pay for the external review;
- Requires insurers to give written notice to patients of their right to an external appeal;
- Requires the external agent to make a determination on an appeal within 30-days or three
days for emergency cases;
- Directs that requests for external reviews are made after the health care plan has rendered
a final adverse coverage determination or after a patient and a health care plan have agreed
to waive any internal appeal;
- Returns the $50 appeal application fee when a denial is reversed by an external review agent
and exempt Medicaid, Child Health Plus and the indigent from the fee;
- Prevents potential conflicts of interest for external reviewers and provides for random selection
of the agents for the cases they review;
- Requires the Health Commissioner and Insurance Superintendent to annually report on the number
and outcomes of external appeals; and,
- Prohibits contracts between providers and insurers from jeopardizing the quality
of and access to necessary services.
