514J.106 Exhaustion of internal grievance process — exceptions — expedited external review request.
1. Except as otherwise provided in this section, a request for an external review shall not be made until the covered person or the covered person’s authorized representative has exhausted the health carrier’s internal grievance process and received a final adverse determination.
2. A covered person or the covered person’s authorized representative shall be considered to have exhausted the health carrier’s internal grievance process if the covered person or the covered person’s authorized representative has filed a grievance involving an adverse determination and, except to the extent the covered person or the covered person’s authorized representative requested or agreed to a delay, has not received a written decision on the grievance from the health carrier within thirty days following the date the covered person or the covered person’s authorized representative filed the grievance with the health carrier.
3. A covered person or the covered person’s authorized representative may file a request for an expedited external review of an adverse determination without exhausting the health carrier’s internal grievance process under either of the following circumstances:
a. The covered person has a medical condition pursuant to which the time frame for completion of an internal review of the grievance involving an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function as provided in section 514J.108.
b. The adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated as provided in section 514J.109.
4. A request for an external review of an adverse determination may be made before the covered person or the covered person’s authorized representative has exhausted the health carrier’s internal grievance procedures whenever the health carrier agrees to waive the exhaustion requirement. If the requirement to exhaust the health carrier’s internal grievance procedures is waived, the covered person or the covered person’s authorized representative may file a request with the commissioner in writing for a standard external review.
2011 Acts, ch 101, §6
Referred to in §514J.107, 514J.109
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