(a) An external appeal agency qualifies to consider external appeals if, with respect to a health care insurance policy, the agency is certified by a qualified private standard-setting organization approved by the director or by a health insurer operating in this state as meeting the requirements imposed under (b) of this section.
(b) An external appeal agency is qualified to consider appeals of health care insurance policy health care decisions if the agency meets the following requirements:
(1) the agency meets the independence requirements of this section;
(2) the agency conducts external appeal activities through a panel of two clinical peers, unless otherwise agreed to by both parties; and
(3) the agency has sufficient medical, legal, and other expertise and sufficient staffing to conduct external appeal activities for the health care insurer on a timely basis consistent with this chapter.
(c) A clinical peer or other entity meets the independence requirements of this section if
(1) the peer or entity does not have a familial, financial, or professional relationship with a related party;
(2) compensation received by a peer or entity in connection with the external review is reasonable and not contingent on any decision rendered by the peer or entity;
(3) the health care insurer has no recourse against the peer or entity in connection with the external review; and
(4) the peer or entity does not otherwise have a conflict of interest with a related party.
(d) In this section, "related party" means
(1) a health care insurer or, with respect to group health care insurance, a plan sponsor, including any officer, director, management employee, or fiduciary of the health care insurer or the plan sponsor;
(2) the health care professional that provided the health care involved in the coverage decision;
(3) the institution at which the health care involved in the coverage decision is provided;
(4) the manufacturer of any drug or other item that was included in the health care involved in the coverage decision;
(5) the covered person; or
(6) any other party that, under the regulations that the director may prescribe, is determined by the director to have a substantial interest in the coverage decision.
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