§ 58-50-82. Expedited external review. - North Carolina Statutes

§ 58‑50‑82. Expedited external review.

(a)        Except as providedin subsection (g) of this section, a covered person may file a request for anexpedited external review with the Commissioner at the time the covered personreceives:

(1)        A noncertificationdecision under G.S. 58‑50‑61(f) if:

a.         The covered personhas a medical condition where the time frame for completion of an expeditedreview of an appeal involving a noncertification set forth in G.S. 58‑50‑61(l)would be reasonably expected to seriously jeopardize the life or health of thecovered person or would jeopardize the covered person's ability to regainmaximum function; and

b.         The covered personhas filed a request for an expedited appeal under G.S. 58‑50‑61(l).

(2)        An appeal decisionunder G.S. 58‑50‑61(k) or (l) upholding a noncertification if:

a.         The noncertificationappeal decision involves a medical condition of the covered person for whichthe time frame for completion of an expedited second‑level grievancereview of a noncertification set forth in G.S. 58‑50‑62(i) wouldreasonably be expected to seriously jeopardize the life or health of thecovered person or jeopardize the covered person's ability to regain maximumfunction; and

b.         The covered personhas filed a request for an expedited second‑level review of anoncertification as set forth in G.S. 58‑50‑61(i); or

(3)        A second‑levelgrievance review decision under G.S. 58‑60‑62(h) or (i) upholding anoncertification:

a.         If the coveredperson has a medical condition where the time frame for completion of astandard external review under G.S. 58‑50‑80 would reasonably beexpected to seriously jeopardize the life or health of the covered person orjeopardize the covered person's ability to regain maximum function; or

b.         If the second‑levelgrievance concerns a noncertification of an admission, availability of care,continued stay, or health care service for which the covered person receivedemergency services, but has not been discharged from a facility.

(b)        Within threebusiness days of receiving a request for an expedited external review, theCommissioner shall complete all of the following:

(1)        Notify the insurerthat made the noncertification, noncertification appeal decision, or second‑levelgrievance review decision which is the subject of the request that the requesthas been received and provide a copy of the request. The Commissioner shallalso request any information from the insurer necessary to make the preliminaryreview set forth in G.S. 58‑50‑80(b)(2) and require the insurer todeliver the information not later than one business day after the request wasmade.

(2)        Determine whetherthe request is eligible for external review and, if it is eligible, determinewhether it is eligible for expedited review.

a.         For a request madepursuant to subdivision (a)(1) of this section that the Commissioner hasdetermined meets the reviewability requirements set forth in G.S. 58‑50‑80(b)(2),determine, based on medical advice from a medical professional who is notaffiliated with the organization that will be assigned to conduct the externalreview of the request, whether the request should be reviewed on an expeditedbasis because the time frame for completion of an expedited review under G.S.58‑50‑61(1) would reasonably be expected to seriously jeopardizethe life or health of the covered person or would jeopardize the coveredperson's ability to regain maximum function. The Commissioner shall then informthe covered person, the covered person's provider who performed or requestedthe service, and the insurer whether the Commissioner has accepted the coveredperson's request for an expedited external review. If the Commissioner hasaccepted the covered person's request for an expedited external review, thenthe Commissioner shall, in accordance with G.S. 58‑50‑80, assign anorganization to conduct the review within the appropriate time frame. If theCommissioner has not accepted the covered person's request for an expeditedexternal review, then the covered person shall be informed by the Commissionerthat the covered person must exhaust, at a minimum, the insurer's internalappeal process under G.S. 58‑50‑61(1) before making another requestfor an external review with the Commissioner.

b.         For a request madepursuant to subdivision (a)(2) of this section that the Commissioner hasdetermined meets the reviewability requirements set forth in G.S. 58‑50‑80(b)(2),the Commissioner shall determine, based on medical advice from a medicalprofessional who is not affiliated with the organization that will be assignedto conduct the external review of the request, whether the request should bereviewed on an expedited basis because the time frame for completion of anexpedited review under G.S. 58‑50‑62 would reasonably be expectedto seriously jeopardize the life or health of the covered person or wouldjeopardize the covered person's ability to regain maximum function. TheCommissioner shall then inform the covered person, the covered person'sprovider who performed or requested the service, and the insurer whether theCommissioner has accepted the covered person's request for an expeditedexternal review. If the Commissioner has accepted the covered person's requestfor an expedited external review, then the Commissioner shall, in accordancewith G.S. 58‑50‑80, assign an organization to conduct the reviewwithin the appropriate time frame. If the Commissioner has not accepted thecovered person's request for an expedited external review, then the coveredperson shall be informed by the Commissioner that the covered person mustexhaust the insurer's internal grievance process under G.S. 58‑50‑62before making another request for an external review with the Commissioner.

c.         For a request madepursuant to sub‑subdivision (a)(3)a. of this section that theCommissioner has determined meets the reviewability requirements set forth inG.S. 58‑50‑80(b)(2), the Commissioner shall determine, based onmedical advice from a medical professional who is not affiliated with theorganization that will be assigned to conduct the external review of therequest, whether the request should be reviewed on an expedited basis becausethe time frame for completion of a standard external review under G.S. 58‑50‑80would reasonably be expected to seriously jeopardize the life or health of thecovered person or would jeopardize the covered person's ability to regainmaximum function. The Commissioner shall then inform the covered person, thecovered person's provider who performed or requested the service, and theinsurer whether the review will be conducted using an expedited or standardtime frame and shall, in accordance with G.S. 58‑50‑80, assign anorganization to conduct the review within the appropriate time frame.

d.         For a request madepursuant to sub‑subdivision (a)(3)b. of this section, that theCommissioner has determined meets the reviewability requirements set forth inG.S. 58‑50‑80(b)(2), the Commissioner shall, in accordance withG.S. 58‑50‑80, assign an organization to conduct the expeditedreview and inform the covered person, the covered person's provider whoperformed or requested the service, and the insurer of its decision.

(c)        As soon aspossible, but within the same business day of receiving notice undersubdivision (b)(2) of this section that the request has been assigned to areview organization, the insurer or its designee utilization revieworganization shall provide or transmit all documents and information consideredin making the noncertification appeal decision or the second‑levelgrievance review decision to the assigned review organization electronically orby telephone or facsimile or any other available expeditious method. A copy ofthe same information shall be sent by the same means or other expeditious meansto the covered person or the covered person's representative who made therequest for expedited external review.

(d)        In addition to thedocuments and information provided or transmitted under subsection (c) of thissection, the assigned organization, to the extent the information or documentsare available, shall consider the following in reaching a decision:

(1)        The covered person'spertinent medical records.

(2)        The attending healthcare provider's recommendation.

(3)        Consulting reportsfrom appropriate health care providers and other documents submitted by theinsurer, covered person, or the covered person's treating provider.

(4)        The most appropriatepractice guidelines that are based on sound clinical evidence and that areperiodically evaluated to assure ongoing efficacy.

(5)        Any applicableclinical review criteria developed and used by the insurer or its designeeutilization review organization in making noncertification decisions.

(6)        Medical necessity,as defined in G.S. 58‑3‑200(b).

(7)        Any documentationsupporting the medical necessity and appropriateness of the provider'srecommendation.

The assigned organizationshall review the terms of coverage under the covered person's health benefitplan to ensure that the organization's decision shall not be contrary to theterms of coverage under the covered person's health benefit plan.

The assigned organization'sdetermination shall be based on the covered person's medical condition at thetime of the initial noncertification decision.

(e)        As expeditiously asthe covered person's medical condition or circumstances require, but not morethan four business days after the date of receipt of the request for anexpedited external review, the assigned organization shall make a decision touphold or reverse the noncertification, noncertification appeal decision, or second‑levelgrievance review decision and notify the covered person, the covered person'sprovider who performed or requested the service, the insurer, and theCommissioner of the decision. In reaching a decision, the assigned organizationis not bound by any decisions or conclusions reached during the insurer'sutilization review process or internal grievance process under G.S. 58‑50‑61and G.S. 58‑50‑62.

(f)         If the noticeprovided under subsection (e) of this section was not in writing, within twodays after the date of providing that notice, the assigned organization shallprovide written confirmation of the decision to the covered person, the coveredperson's provider who performed or requested the service, the insurer, and theCommissioner and include the information set forth in G.S. 58‑50‑80(k).

Upon receipt of the notice ofa decision under subsection (e) of this section that reverses thenoncertification, noncertification appeal decision, or second‑levelgrievance review decision, the insurer shall within one day reverse thenoncertification, noncertification appeal decision, or second‑levelgrievance review decision that was the subject of the review and shall providecoverage or payment for the requested health care service or supply that wasthe subject of the noncertification, noncertification appeal decision, orsecond‑level grievance review decision.

(g)        An expeditedexternal review shall not be provided for retrospective noncertifications.  (2001‑446, s. 4.5;2005‑223, ss. 10(b), 11, 12; 2007‑298, ss. 3.1, 3.2; 2009‑382,ss. 28‑30.)