§432E-6.5 Expedited internal appeal, when authorized; standard for decision. (a) An enrollee may request that the internal appeal under section 432E-5 be conducted as an expedited appeal. If a request for expedited appeal is approved by the health carrier, the appropriate internal appeal shall be completed within seventy-two hours of receipt of the request for expedited appeal.
(b) An expedited appeal shall be authorized if the application of the sixty day standard review time frame may:
(1) Seriously jeopardize the life or health of the enrollee;
(2) Seriously jeopardize the enrollee's ability to gain maximum functioning; or
(3) Subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the expedited appeal.
(c) The decision as to whether an enrollee's complaint is an expedited appeal shall be made by applying the standard of a reasonable individual who is not a trained health professional. The decision may be made for the managed care plan by an individual acting on behalf of the managed care plan. If a licensed health care provider with knowledge of a claimant's medical condition requests an expedited appeal on behalf of an enrollee, the request shall be treated as an expedited appeal. [L 2000, c 250, §2; am L 2004, c 27, §2; am L 2011, c 230, §§8, 9]
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