A. 1. Each health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage it provides to covered persons.
2. The disclosure required by paragraph 1 of this subsection shall be in a format prescribed by the Insurance Commissioner.
B. The description required under subsection A of this section shall include a statement that informs the covered person of the right of the covered person to file a request for an external review of an adverse determination or final adverse determination with the Commissioner. The statement shall explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care or effectiveness. The statement shall include the telephone number and address of the Commissioner.
C. In addition to subsection B of this section, the statement shall inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.
Added by Laws 2011, c. 278, § 51 and Laws 2011, c. 360, § 41.
NOTE: Laws 2011, c. 278, § 51 and Laws 2011, c. 360, § 41 added identical sections under the same number.
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