(a) A health care insurer offering a health care insurance policy shall provide for an external appeal process that meets the requirements of this section in the case of an externally appealable decision for which a timely appeal is made in writing either by the health care insurer or by the covered person.
(b) A health care insurer may condition the use of an external appeal process in the case of an externally appealable decision upon a final decision in an internal appeal under AS 21.07.020 , but only if the decision is made in a timely basis consistent with the deadlines provided under this chapter.
(c) Except as provided in this subsection, the external appeal process shall be conducted under a contract between the health care insurer and one or more external appeal agencies that are qualified under AS 21.07.060 . The health care insurer shall provide
(1) that the selection process among external appeal agencies qualifying under AS 21.07.060 does not create any incentives for external appeal agencies to make a decision in a biased manner;
(2) for auditing a sample of decisions by external appeal agencies to ensure that decisions are not made in a biased manner; and
(3) that all costs of the process, except those incurred by the covered person or treating professional in support of the appeal, shall be paid by the health care insurer and not by the covered person.
(d) An external appeal process must include at least the following:
(1) a fair, de novo determination based on coverage provided by the policy and by applying terms as defined by the policy; however, nothing in this paragraph may be construed as providing for coverage of items and services for which benefits are excluded under the policy or coverage;
(2) an external appeal agency shall determine whether the health care insurer's decision is
(A) in accordance with the medical needs of the patient involved, as determined by the health care insurer, taking into account, as of the time of the health care insurer's decision, the patient's medical needs and any relevant and reliable evidence the agency obtains under (3) of this subsection; and
(B) in accordance with the scope of the covered benefits under the policy; if the agency determines the decision complies with this paragraph, the agency shall affirm the decision, and, to the extent that the agency determines the decision is not in accordance with this paragraph, the agency shall reverse or modify the decision;
(3) the external appeal agency shall include among the evidence taken into consideration
(A) the decision made by the health care insurer upon internal appeal under AS 21.07.020 and any guidelines or standards used by the health care insurer in reaching a decision;
(B) any personal health and medical information supplied with respect to the individual whose denial of claim for benefits has been appealed;
(C) the opinion of the individual's treating physician or health care provider; and
(D) the health care insurance policy;
(4) the external appeal agency may also take into consideration the following evidence:
(A) the results of studies that meet professionally recognized standards of validity and replicability or that have been published in peer-reviewed journals;
(B) the results of professional consensus conferences conducted or financed in whole or in part by one or more government agencies;
(C) practice and treatment guidelines prepared or financed in whole or in part by government agencies;
(D) government-issued coverage and treatment policies;
(E) generally accepted principles of professional medical practice;
(F) to the extent that the agency determines them to be free of any conflict of interest, the opinions of individuals who are qualified as experts in one or more fields of health care that are directly related to the matters under appeal;
(G) to the extent that the agency determines them to be free of any conflict of interest, the results of peer reviews conducted by the health care insurer involved;
(H) the community standard of care; and
(I) anomalous utilization patterns;
(5) an external appeal agency shall determine
(A) whether a denial of a claim for benefits is an externally appealable decision;
(B) whether an externally appealable decision involves an expedited appeal; and
(C) for purposes of initiating an external review, whether the internal appeal process has been completed;
(6) a party to an externally appealable decision may submit evidence related to the issues in dispute;
(7) the health care insurer involved shall provide the external appeal agency with access to information and to provisions of the policy relating to the matter of the externally appealable decision, as determined by the external appeal agency; and
(8) a determination by the external appeal agency on the decision must
(A) be made orally or in writing and, if it is made orally, shall be supplied to the parties in writing as soon as possible;
(B) be made in accordance with the medical exigencies of the case involved, but in no event later than 21 working days after the appeal is filed, or, in the case of an expedited appeal, 72 hours after the time of requesting an external appeal of the health care insurer's decision;
(C) state, in layperson's language, the basis for the determination, including, if relevant, any basis in the terms or conditions of the policy; and
(D) inform the covered person of the individual's rights, including any time limits, to seek further review by the courts of the external appeal determination.
(e) If the external appeal agency reverses or modifies the denial of a claim for benefits, the health care insurer shall
(1) upon receipt of the determination, authorize benefits in accordance with that determination;
(2) take action as may be necessary to provide benefits, including items or services, in a timely manner consistent with the determination; and
(3) submit information to the external appeal agency documenting compliance with the agency's determination.
(f) A decision of an external appeal agency is binding unless a person who is aggrieved by a final decision of an external appeal agency appeals the decision to the superior court.
(g) An appeal of a final decision of an external appeal agency must be filed within six months after the date of the decision of the external appeal agency.
(h) In this section, "externally appealable decision"
(1) means
(A) a denial of a claim for benefits that is based in whole or in part on a decision that the item or service is not medically necessary or appropriate or is investigational or experimental, or in which the decision as to whether a benefit is covered involves a medical judgment; or
(B) a denial that is based on a failure to meet an applicable deadline for internal appeal under AS 21.07.020 ;
(2) does not include a decision based on specific exclusions or express limitations on the amount, duration, or scope of coverage that do not involve medical judgment, or a decision regarding whether an individual is a participant, beneficiary, or other covered person under the policy.
Section: Previous 21.07.010 21.07.020 21.07.030 21.07.040 21.07.050 21.07.060 21.07.070 21.07.080 21.07.090 21.07.250 NextLast modified: November 15, 2016