Pennsylvania Statutes Title 40 P.S. Insurance § 991.2164f. Expedited external review

(1) An adverse benefit determination, if either of the following applies:

(2) A final adverse benefit determination if either of the following apply:

(1) Upon receipt of a request for an expedited external review, the department shall, within 24 hours, send a copy of the request to the insurer.

(2) Within 24 hours upon receipt of a request under paragraph (1), the insurer shall determine whether the request meets the requirements for review under section 2164.5(b). The insurer shall, within 24 hours, notify the department, the covered person and, if applicable, the covered person's authorized representative of the insurer's eligibility determination.

(3) Notification provided under paragraph (2) 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.

(4) Notwithstanding an insurer's initial determination that the request is ineligible for review, the department may decide, based upon the terms of the covered person's health insurance policy, that a request is eligible for external review under section 2164.5(b). The department's decision shall be binding on the insurer and the covered person and may be appealed to the commissioner. Consideration of an appeal may not delay or terminate the external review.

(5) Upon receipt of the notice that the request meets the requirements for review, the department shall, within 24 hours, assign an IRO to conduct the expedited external review from the list of approved IROs compiled and maintained by the department under section 2164.9.  3 The department shall, within 24 hours, notify the insurer of the name of the assigned IRO.

(6) In reaching a decision in accordance with subsection (e), the assigned IRO shall not be bound by a decision or conclusion reached during the internal adverse benefit determination process for an insurer under section 2164.

(1) Electronically.

(2) By telephone.

(3) By facsimile.

(4) By any other available expeditious method.

(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 any 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) As expeditiously as the covered person's medical condition or circumstances require, but in no event more than 72 hours after the date of receipt of the request for an expedited external review that meets the reviewability requirements under section 2164.5(b), the assigned IRO shall provide notice of the IRO's decision to uphold or reverse the adverse benefit determination or the final adverse benefit determination to:

(2) If the notice provided under paragraph (1) is not in writing, within 48 hours of the date of providing that notice, 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:

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

(4) 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.