Current through Reg. 50, No. 13; March 28, 2025
(a) Appeal of prospective or concurrent
review adverse determinations. Each URA must comply with its written procedures
for appeals. The written procedures for appeals must comply with Insurance Code
Chapter 4201, Subchapter H, concerning Appeal of Adverse Determination, and
must include provisions that specify the following:
(1) Time frames for filing the written or
oral appeal, which may not be less than 30 calendar days after the date of
issuance of written notification of an adverse determination.
(2) An enrollee, an individual acting on
behalf of the enrollee, or the provider of record may appeal the adverse
determination orally or in writing.
(3) An appeal acknowledgement letter must:
(A) be sent to the appealing party within
five working days from receipt of the appeal;
(B) acknowledge the date the URA received the
appeal;
(C) include a list of
relevant documents that must be submitted by the appealing party to the URA;
and
(D) include a one-page appeal
form to be filled out by the appealing party when the URA receives an oral
appeal of an adverse determination.
(4) Appeal decisions must be made by a
physician who has not previously reviewed the case.
(5) In any instance in which the URA is
questioning the medical necessity, the appropriateness, or the experimental or
investigational nature, of the health care services prior to issuance of
adverse determination, the URA must afford the provider of record a reasonable
opportunity to discuss the plan of treatment for the enrollee with a physician.
The provision must require that the discussion include, at a minimum, the
clinical basis for the URA's decision.
(6) If an appeal is requested or denied and,
within 10 working days from the request or denial, the health care provider
requests a particular type of specialty provider review the case, the appeal or
the decision denying the appeal must be reviewed by a health care provider in
the same or similar specialty that typically manages the medical, dental, or
specialty condition, procedure, or treatment under discussion for review of the
adverse determination. The specialty review must be completed within 15 working
days of receipt of the request. The provision must state that notification of
the appeal under this paragraph must be in writing.
(7) In addition to the written appeal, a
method for expedited appeals is available for denials of emergency care,
continued stays for hospitalized enrollees, or prescription drugs or
intravenous infusions for which an enrollee is receiving benefits under the
health insurance policy; adverse determinations of a step therapy protocol
exception request under Insurance Code §
1369.0546; or a denial
of another service if the requesting health care provider includes a written
statement with supporting documentation that the service is necessary to treat
a life-threatening condition or prevent serious harm to the patient. The
provision must state that:
(A) the procedure
must include a review by a health care provider who has not previously reviewed
the case and who is of the same or a similar specialty as the health care
provider that typically manages the medical condition, procedure, or treatment
under review;
(B) an expedited
appeal must be completed based on the immediacy of the medical or dental
condition, procedure, or treatment, but may in no event exceed one working day
from the date all information necessary to complete the appeal is received;
and
(C) an expedited appeal
determination may be provided by telephone or electronic transmission but must
be followed with a letter within three working days of the initial telephonic
or electronic notification.
(8) After the URA has sought review of the
appeal of the adverse determination, the URA must issue a response letter to
the enrollee or an individual acting on behalf of the enrollee, and the
provider of record, explaining the resolution of the appeal. If there is an
adverse determination of the appeal, the letter must include:
(A) a statement of the specific medical,
dental, or contractual reasons for the resolution;
(B) the clinical basis for the
decision;
(C) a description of or
the source of the screening criteria that were utilized in making the
determination;
(D) the professional
specialty of the physician who made the determination;
(E) notice of the appealing party's right to
seek review of the adverse determination by an IRO under §
19.1717 of this title (relating to
Independent Review of Adverse Determinations);
(F) notice of the independent review
process;
(G) a copy of a request
for a review by an IRO form; and
(H) procedures for filing a complaint as
described in §
19.1705(f) of
this title (relating to General Standards of Utilization
Review).
(9) A statement
that the appeal must be resolved as soon as practical, but, under Insurance
Code §
4201.359 and §
1352.006, in no case
later than 30 calendar days after the date the URA receives the appeal from the
appealing party referenced under paragraph (3) of this subsection.
(10) In a circumstance involving an
enrollee's life-threatening condition or the denial of prescription drugs or
intravenous infusions for which the enrollee is receiving benefits under the
health insurance policy, the enrollee is entitled to an immediate appeal to an
IRO and is not required to comply with procedures for an appeal of the URA's
adverse determination.
(b) Appeal of retrospective review adverse
determinations. A URA must maintain and make available a written description of
the appeal procedures involving an adverse determination in a retrospective
review. The written procedures for appeals must specify that an enrollee, an
individual acting on behalf of the enrollee, or the provider of record may
appeal the adverse determination orally or in writing. The appeal procedures
must comply with:
(1) Chapter 21, Subchapter
T, of this title (relating to Submission of Clean Claims), if
applicable;
(2) Section
19.1709 of this title (relating to
Notice of Determinations Made in Utilization Review), for retrospective
utilization review adverse determination appeals; and
(3) Insurance Code §
4201.359.
(c) Appeals concerning an acquired brain
injury. A URA must comply with this subsection in regard to a determination
concerning an acquired brain injury as defined by §
21.3102 of this title (relating to
Definitions). Not later than three business days after the date on which an
individual requests utilization review or requests an extension of coverage
based on medical necessity or appropriateness, a URA must provide notification
of the determination through a direct telephone contact to the individual
making the request. This subsection does not apply to a determination made for
coverage under a small employer health benefit plan.
