(a) (1) Notice of an adverse determination or a nonmedical denial shall be provided to the healthcare provider that initiated the prior authorization or nonmedical review.
(2) Notice may be made by fax or hard copy letter sent by regular mail or verbally, as requested by the subscriber's healthcare provider.
(b) The written or verbal notice required under this section shall include:
(1) (A) The name, title, address, and telephone number of the healthcare professional responsible for making the adverse determination or nonmedical denial.
(B) For a physician, the notice shall identify the physician's board certification status or board eligibility.
(C) The notice under this section shall identify each state in which the healthcare professional is licensed and the license number issued to the professional by each state;
(2) The written clinical criteria, if any, and any internal rule, guideline, or protocol on which the healthcare insurer relied when making the adverse determination or nonmedical denial and how those provisions apply to the subscriber's specific medical circumstance;
(3) Information for the subscriber and the subscriber's healthcare provider that describes the procedure through which the subscriber or healthcare provider may request a copy of any report developed by personnel performing the review that led to the adverse determination or nonmedical denial; and
(4) (A) Information that explains to the subscriber and the subscriber's healthcare provider the right to appeal the adverse determination or nonmedical denial.
(B) The information required under subdivision (b)(4)(A) of this section shall include instructions concerning how to perfect an appeal and how the subscriber and the subscriber's healthcare provider may ensure that written materials supporting the appeal will be considered in the appeal process.
(C) The information required under subdivision (b)(4)(A) of this section shall include addresses and telephone numbers to be used by healthcare providers and subscribers to make complaints to the Arkansas State Medical Board, the State Board of Health, and the State Insurance Department.
(c) (1) When a healthcare service for the treatment or diagnosis of any medical condition is restricted or denied for use by nonmedical review, step therapy, or a fail first protocol in favor of a healthcare service preferred by the healthcare insurer, the subscriber's healthcare provider shall have access to a clear and convenient process to expeditiously request an override of that restriction or denial from the healthcare insurer.
(2) Upon request, the subscriber's healthcare provider shall be provided contact information, including a phone number, for a person to initiate the request for an expeditious override of the restriction or denial.
(d) The appeal process described in subdivisions (b)(2)-(4) of this section shall not apply when a healthcare service is denied due to the fact that the healthcare service is not a covered service under the health benefit plan.
Section: Previous 23-99-1102 23-99-1103 23-99-1104 23-99-1105 23-99-1106 23-99-1107 23-99-1108 23-99-1109 23-99-1110 23-99-1111 23-99-1112 23-99-1113 23-99-1114 NextLast modified: November 15, 2016