External review: Duties of external review organization; contents and submission of decision by organization; costs; regulations.
1. Not later than 5 business days after the date that an external review organization receives a request for an external review, the external review organization shall:
(a) Review the documents and materials submitted for the external review; and
(b) Notify the injured employee, his employer and the insurer whether the external review organization needs any additional information to conduct the external review.
2. The external review organization shall render a decision on the matter not later than 15 business days after the date that it receives all information that is necessary to conduct the external review.
3. In conducting the external review, the external review organization shall consider, without limitation:
(a) The medical records of the insured;
(b) Any recommendations of the physician of the insured; and
(c) Any other information approved by the Commissioner for consideration by an external review organization.
4. In its decision, the external review organization shall specify the reasons for its decision. The external review organization shall submit a copy of its decision to:
(a) The injured employee;
(b) The employer;
(c) The insurer; and
(d) The appeals officer, if any.
5. The insurer shall pay the costs of the services provided by the external review organization.
6. The Commissioner may adopt regulations to govern the process of external review and to carry out the provisions of this section. Any regulations adopted pursuant to this section must provide that:
(a) All parties must agree to the submission of a matter to an external review organization before a request for external review may be submitted;
(b) A party may not be ordered to submit a matter to an external review organization; and
(c) The findings and decisions of an external review organization are not binding.
Last modified: February 25, 2006