1. In a case involving an initial determination or a concurrent review determination,
a health carrier shall give the provider rendering the service an opportunity to request
on behalf of the enrollee a reconsideration of an adverse determination by the reviewer
making the adverse determination.
2. The reconsideration shall occur within one working day of the receipt of the request
and shall be conducted between the provider rendering the service and the reviewer
who made the adverse determination or a clinical peer designated by the reviewer if
the reviewer who made the adverse determination is not available within one working
3. If the reconsideration process does not resolve the difference of opinion, the
adverse determination may be appealed by the enrollee or the provider on behalf of
the enrollee. Reconsideration is not a prerequisite to a standard appeal or an expedited appeal
of an adverse determination.
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