Pennsylvania Statutes Title 40 P.S. Insurance § 991.2164e. Standard external review

(1) A covered person, or the covered person's authorized representative, may file a request for external review with the department within four months after the date of receipt of a notice of an adverse benefit determination or final adverse benefit determination under section 2164.2.  1

(2) The department shall send a copy of the request to the insurer within one business day of the date of receipt of a request for external review under paragraph (1).

(1) The individual is or was a covered person under the health insurance policy at the time the health care service was requested or, in the case of a retrospective utilization review, was a covered person under the health insurance policy at the time the health care service was provided.

(2) The health care service that is the subject of the adverse benefit determination or the final adverse benefit determination is a covered benefit under the covered person's health insurance policy, except for a determination by the insurer that the health care service is not covered because it does not meet the insurer's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness.

(3) The covered person has exhausted the insurer's internal appeal process under section 2164,  2 unless the covered person is not required to exhaust the insurer's internal appeal process under section 2164.4.  3

(4) The covered person has not provided all the information and forms required to process an external review, including the release form provided under section 2164.2(b).

(1) Within one business day of completion of the preliminary review, the insurer shall notify the department and the covered person and, if applicable, the covered person's authorized representative in writing whether the request is complete and eligible for external review. The following apply:

(2) Notification under paragraph (1)(ii) shall be provided in a form as specified by the department and include a statement informing the covered person and, if applicable, the covered person's authorized representative that an insurer's initial determination that the external review request is ineligible for review may be appealed to the department.

(3) Notwithstanding an insurer's initial determination that the request is ineligible for review, the department may determine, based upon the terms of the covered person's health insurance policy, that a request is eligible for external review under subsection (b). The determination shall be binding on the insurer and the covered person and may be appealed to the commissioner. Consideration of the appeal may not delay or terminate the external review.

(1) Within one business day of the date of receipt of notice that a request is eligible for external review following the preliminary review conducted under subsection (c), the department shall:

(2) The assigned IRO shall not be bound by a decision or conclusion reached during the insurer's internal claims and appeal process under section 2164.

(1) Within five business days of the date of receipt of the notice provided under subsection (d)(1), the insurer, or a utilization review organization designated by the insurer, shall provide to the assigned IRO the documents and information considered in making the adverse benefit determination or final adverse benefit determination.

(2) If the insurer, or a utilization review organization designated by the insurer, fails to provide documents and information within the time period specified in paragraph (1), the IRO may proceed with the review, terminate the external review and make a decision to reverse the adverse benefit determination or final adverse benefit determination. Within one business day of making the decision under paragraph (1), the IRO shall notify the department, the insurer, the covered person and, if applicable, the covered person's authorized representative.

(1) The assigned IRO shall review all of the information and documents received under subsection (e) and other information submitted in writing to the IRO by the covered person or the covered person's authorized representative under subsection (d)(1)(ii).

(2) Within one business day of receipt of information submitted by the covered person or the covered person's authorized representative, the assigned IRO shall forward the information to the insurer.

(1) Upon receipt of the information, if any, required to be forwarded under subsection (f)(2), the insurer may reconsider an adverse benefit determination or final adverse benefit determination that is the subject of the external review.

(2) Reconsideration by the insurer of an adverse benefit determination or final adverse benefit determination under paragraph (1) may not delay or terminate the external review.

(3) The external review may be terminated without an IRO determination only if the insurer decides, upon completion of the insurer's reconsideration, to reverse the insurer's adverse benefit determination or final adverse benefit determination and provide coverage or payment for the recommended health care service that is the subject of the external review.

(4) Within one business day of making the decision to reverse its adverse benefit determination or final adverse benefit determination, as provided in paragraph (3), the insurer shall notify the department, the assigned IRO, the covered person and, if applicable, the covered person's authorized representative in writing of its decision.

(5) The assigned IRO shall terminate the external review upon receipt of the notice from the insurer sent under paragraph (4).

(1) The covered person's medical records.

(2) The attending health care provider's recommendation.

(3) Consulting reports from appropriate health care providers and other documents submitted by the insurer, the covered person or the covered person's authorized representative.

(4) The terms of coverage under the covered person's health insurance policy to ensure that the IRO's decision is not contrary to the terms of coverage.

(5) The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include other practice guidelines developed by the Federal Government or national or professional medical societies, boards and associations.

(6) Applicable clinical review criteria developed and used by the insurer or a utilization review organization designated by the insurer.

(7) The opinion of the IRO's clinical reviewer or reviewers after considering the information under paragraphs (1), (2), (3), (4), (5) and (6).

(1) Within 45 days of the date of receipt of the request for an external review, the assigned IRO shall provide written notice of the IRO's decision to uphold or reverse the adverse benefit determination or the final adverse benefit determination to:

(2) The IRO shall include in the notice under paragraph (1):

(3) Upon receipt of a notice of a decision under paragraph (1) reversing the adverse benefit determination or final adverse benefit determination, the insurer shall within 24 hours approve the coverage that was the subject of the adverse benefit determination or final adverse benefit determination.