Effective 28 Aug 1997
376.1365. Reconsideration of an adverse determination, when. — 1. In a case involving an initial determination or a concurrent review determination, a health carrier shall give the provider rendering the service an opportunity to request on behalf of the enrollee a reconsideration of an adverse determination by the reviewer making the adverse determination.
2. The reconsideration shall occur within one working day of the receipt of the request and shall be conducted between the provider rendering the service and the reviewer who made the adverse determination or a clinical peer designated by the reviewer if the reviewer who made the adverse determination is not available within one working day.
3. If the reconsideration process does not resolve the difference of opinion, the adverse determination may be appealed by the enrollee or the provider on behalf of the enrollee. Reconsideration is not a prerequisite to a standard appeal or an expedited appeal of an adverse determination.
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(L. 1997 H.B. 335)
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