Louisiana Revised Statutes 22:2437 – Expedited external review
Terms Used In Louisiana Revised Statutes 22:2437
- Adverse determination: means any of the following:
(a) A determination by a health insurance issuer or its designee utilization review organization that, based upon the information provided, a request for a benefit under the health insurance issuer's health benefit plan upon application of any utilization review technique does not meet the health insurance issuer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced, or terminated or payment is not provided or made, in whole or in part, for the benefit. See Louisiana Revised Statutes 22:2392
- Authorized representative: means any of the following:
(a) A person to whom a covered person has given express written consent to represent the covered person for purposes of this Chapter. See Louisiana Revised Statutes 22:2392
- Clinical peer: means a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review. See Louisiana Revised Statutes 22:2392
- Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the health insurance issuer to determine the medical necessity and appropriateness of health care services including those used in the determination of an item or health care service as experimental. See Louisiana Revised Statutes 22:2392
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:2392
- Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Louisiana Revised Statutes 22:2392
- Emergency services: means health care items and services furnished or required to evaluate and treat an emergency medical condition. See Louisiana Revised Statutes 22:2392
- Facility: means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, rehabilitation and other therapeutic health settings, and inpatient hospice facilities. See Louisiana Revised Statutes 22:2392
- Final adverse determination: means an adverse determination, including medical judgment, involving a covered benefit that has been upheld by a health insurance issuer, or its designee utilization review organization, at the completion of the health insurance issuer's internal claims and appeals process procedures provided pursuant to Louisiana Revised Statutes 22:2392
- Grievance: means , in a health insurance issuer's internal claims and appeals process, a written complaint or oral complaint, if the complaint involves an urgent care request submitted by or on behalf of a covered person regarding any of the following:
(a) Availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review. See Louisiana Revised Statutes 22:2392
- Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a health insurance issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Louisiana Revised Statutes 22:2392
- Health care professional: means a physician or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law. See Louisiana Revised Statutes 22:2392
- Health insurance issuer: means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including through a health benefit plan as defined in this Section, and shall include a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits. See Louisiana Revised Statutes 22:2392
- Immediately: means as expeditiously as the medical situation of the covered person requires but in no event longer than one day for expedited reviews or one business day for standard reviews. See Louisiana Revised Statutes 22:2392
- Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Louisiana Revised Statutes 22:2392
- person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
- provider: means a health care professional or a facility. See Louisiana Revised Statutes 22:2392
- Uphold: The decision of an appellate court not to reverse a lower court decision.
- Utilization review: means a set of formal techniques designed to monitor the use of or evaluate the clinical or medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings. See Louisiana Revised Statutes 22:2392
- Utilization review organization: means a licensed entity that conducts utilization review in the internal claims and appeals process provided pursuant to Louisiana Revised Statutes 22:2392
A. Except as provided in Subsection F of this Section, a covered person or his authorized representative may make a request regardless of the claim amount for an expedited external review with the health insurance issuer at the time that the covered person receives:
(1) An adverse determination if both of the following apply:
(a) The adverse determination involves a medical condition of the covered person for which the time frame for completion of an expedited internal review of a grievance involving an adverse determination made pursuant to La. Rev. Stat. 22:2401 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function.
(b) The covered person or his authorized representative has filed a request for an expedited review of a grievance involving an adverse determination made pursuant to La. Rev. Stat. 22:2401.
(2) A final adverse determination if either of the following applies:
(a) The covered person has a medical condition in which the time frame for completion of a standard external review pursuant to La. Rev. Stat. 22:2436 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function.
(b) The final adverse determination concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services, but has not been discharged from a facility.
B.(1) Immediately upon receipt of the request pursuant to Subsection A of this Section, the health insurance issuer shall determine whether the request meets the reviewability requirements specified in La. Rev. Stat. 22:2436(B). The health insurance issuer shall immediately notify the covered person and, if applicable, his authorized representative of its eligibility determination.
(2)(a) The commissioner may specify the form and method for the health insurance issuer’s notice of initial determination pursuant to Paragraph (1) of this Subsection and any supporting information to be included in the notice.
(b) The notice of initial determination pursuant to Paragraph (1) of this Subsection shall include a statement informing the covered person and, if applicable, his authorized representative that a health insurance issuer’s initial determination that an expedited external review request is ineligible for review may be appealed to the commissioner.
(3)(a) If the covered person or his authorized representative makes a written request to the commissioner of insurance after receipt of the notice of denial of an expedited external review, the commissioner may determine that a request is eligible for an expedited external review in accordance with the criteria found in La. Rev. Stat. 22:2436(B), notwithstanding a health insurance issuer’s initial determination that the request is ineligible, and require that it be referred for external review.
(b) In making a determination under Subparagraph (a) of this Paragraph, the commissioner’s decision shall be made in accordance with all applicable provisions of this Part.
(c) The commissioner shall immediately notify the health insurance issuer and the covered person or his authorized representative of its determination about the eligibility of the request. Following receipt of the commissioner’s determination that a request is eligible for an expedited external review, a health insurance issuer shall immediately comply with Paragraph (4) of this Subsection.
(4) Immediately upon the health insurance issuer’s determination that a request is eligible for an expedited external review or upon the determination by the commissioner that a request is eligible for an expedited external review, the health insurance issuer shall submit a request for assignment of an independent review organization through the Department of Insurance’s website. Upon receipt of the notice that the request meets the reviewability requirements, the commissioner shall immediately assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations compiled and maintained by the commissioner pursuant to La. Rev. Stat. 22:2440. The commissioner shall immediately notify the health insurance issuer and the covered person or his authorized representative of the name and contact information of the assigned independent review organization.
(5) In reaching a decision in accordance with Subsection E of this Section, the assigned independent review organization is not bound by any decisions or conclusions reached during the health insurance issuer’s utilization review process or the health insurance issuer’s internal claims and appeals process provided pursuant to La. Rev. Stat. 22:2401.
C.(1) Upon receipt of the notice from the commissioner of the name of the independent review organization assigned to conduct the expedited external review pursuant to Paragraph (B)(4) of this Section, the health insurance issuer or its designee utilization review organization shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization electronically, by telephone or facsimile, or by any other available expeditious method.
(2) Any information required by Paragraph (1) of this Subsection and not received from a health insurance issuer as expeditiously as is necessary for consideration in reaching a decision required in Subsection E of this Section shall be presumed to include the information that is the most favorable to a covered person in reaching a decision required in Subsection E of this Section.
D. In addition to the documents and information provided or transmitted pursuant to Subsection C of this Section, the assigned independent review organization, to the extent the information or documents are available, shall consider the following in reaching a decision:
(1) The covered person’s pertinent medical records.
(2) The attending health care professional‘s recommendation.
(3) Consulting reports from appropriate health care professionals and other documents submitted by the health insurance issuer, the covered person, his authorized representative, or the covered person’s treating provider.
(4) The terms of coverage under the covered person’s health benefit plan with the health insurance issuer to ensure that the independent review organization’s decision is not contrary to the terms of coverage under the covered person’s health benefit plan with the health insurance issuer.
(5) The most appropriate practice guidelines, which shall include 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) Any applicable clinical review criteria developed and used by the health insurance issuer or its designee utilization review organization in making adverse determinations.
(7) The opinion of the independent review organization’s clinical peer or peers after considering the information specified by Paragraphs (1) through (6) of this Subsection to the extent the information and documents are available and the clinical peer or peers consider appropriate.
E.(1) As expeditiously as the covered person’s medical condition or circumstances requires, but in no event more than seventy-two hours after the date that the health insurance issuer receives the request for an expedited external review, the assigned independent review organization shall do both of the following:
(a) Make a decision to uphold or reverse the adverse determination or final adverse determination.
(b) Notify the covered person, his authorized representative, if applicable, the health insurance issuer, and the commissioner of the decision.
(2) If the notice provided pursuant to Paragraph (1) of this Subsection was not in writing, within forty-eight hours after the date of providing that notice, the assigned independent review organization shall do both of the following:
(a) Provide written confirmation of the decision to the covered person, his authorized representative, if applicable, the health insurance issuer, and the commissioner.
(b) Include the information specified in La. Rev. Stat. 22:2436(I)(2).
(3) Upon receipt of the notice of a decision pursuant to Paragraph (1) of this Subsection reversing the adverse determination or final adverse determination, the health insurance issuer shall immediately approve the coverage that was the subject of the adverse determination or final adverse determination.
F. An expedited external review shall not be provided for retrospective adverse determinations or retrospective final adverse determinations.
G. The assignment by the commissioner of an approved independent review organization to conduct an expedited external review in accordance with this Section shall be done on a random basis among those approved independent review organizations qualified to conduct the particular expedited external review based on the nature of the health care service that is the subject of the adverse determination or final adverse determination and other circumstances, including conflict of interest concerns pursuant to La. Rev. Stat. 22:2441(D).
Acts 2013, No. 326, §1, eff. Jan. 1, 2015; Acts 2022, No. 81, §1, eff. Jan. 1, 2023.