§2433.  Notice of right to external review

A.(1)  For matters involving an issue of medical necessity, appropriateness, health care setting, level of care, effectiveness, or a rescission, a health insurance issuer shall notify the covered person in writing of the covered person's right to request an external review to be conducted pursuant to R.S. 22:2436 through 2438 and include the appropriate statements and information set forth in Subsection B of this Section at the same time that the health insurance issuer sends written notice of:

(a)  An adverse determination upon completion of the health insurance issuer's internal claims and appeals process provided pursuant to R.S. 22:2401.

(b)  A final adverse determination.

(2)  As part of the written notice required pursuant to Paragraph (1) of this Subsection, a health insurance issuer shall include the following, or substantially equivalent, language: "We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us. In order to request an external appeal, you should send your request in writing to our office at the designated address included in this notice."

(3)  The commissioner may prescribe by regulation the form and content of the notice required pursuant to this Section.

B.(1)  The health insurance issuer shall include in the notice required pursuant to Subsection A of this Section:

(a)  For a notice related to an adverse determination, a statement informing the covered person that:

(i)  If the covered person has a medical condition for which the time frame for completion of an expedited review of a grievance involving an adverse determination as provided pursuant to R.S. 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, the covered person or his authorized representative may file a request for an expedited external review to be conducted pursuant to R.S. 22:2437.  Further, the notice shall inform the covered person that an expedited external review pursuant to R.S. 22:2438 is available if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating physician certifies in writing that any delay in appealing the adverse determination may pose an imminent threat to the covered person's health, including but not limited to severe pain, potential loss of life, limb, or major bodily function, or the immediate deterioration of the health of the covered person.  The notice shall also inform the covered person or his authorized representative that he may simultaneously file a  request for an expedited review of a grievance involving an adverse determination as provided pursuant to R.S. 22:2401, but that the independent review organization assigned to conduct the expedited external review will determine whether the covered person shall be required to complete the expedited review of the grievance prior to conducting the expedited external review.

(ii)  The covered person or his authorized representative may file a grievance under the health insurance issuer's internal claims and appeals process as provided pursuant to R.S. 22:2401, but if the health insurance issuer has not issued a written decision to the covered person or his authorized representative within thirty days following the date the covered person or his authorized representative files the grievance with the health insurance issuer and the covered person or his authorized representative has not requested or agreed to a delay, the covered person or his authorized representative may file a request for external review pursuant to R.S. 22:2434 and shall be considered to have exhausted the health insurance issuer's internal claims and appeals process for purposes of R.S. 22:2435.

(b)  For a notice related to a final adverse determination, a statement informing the covered person that:

(i)  If the covered person has a medical condition for which  the time frame for completion of a standard external review pursuant to R.S. 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, the covered person or his authorized representative may file a request for an expedited external review pursuant to R.S. 22:2437.

(ii)  If the final adverse determination concerns either of the following:

(aa)  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, the covered person or his authorized representative may request an expedited external review pursuant to R.S. 22:2437.

(bb)  A denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational, the covered person or his authorized representative may file a request for a standard external review to be conducted pursuant to R.S. 22:2438 or if the covered person's treating physician certifies in writing that any delay in appealing the adverse determination may pose an imminent threat to the covered person's health, including but not limited to severe pain, potential loss of life, limb, or major bodily function, or the immediate deterioration of the health of the covered person, the covered person or his authorized representative may request an expedited external review to be conducted under R.S. 22:2438.

(2)  In addition to the information to be provided pursuant to Paragraph (1) of this Subsection, the health insurance issuer shall include a copy of the description of both the standard and expedited external review procedures the health insurance issuer is required to provide pursuant to R.S. 22:2445, highlighting the provisions in the external review procedures that give the covered person or his authorized representative the opportunity to submit additional information and including any forms used to process an external review.

(3)  As part of any forms provided under Paragraph (2) of this Subsection, the health insurance issuer shall include an authorization form, or other document approved by the commissioner that complies with the requirements of 45 CFR Section 164.508, by which the covered person, for purposes of conducting an external review under this Part, authorizes the health insurance issuer and the covered person's treating health care provider to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review, as further provided in this Paragraph.  A health insurance issuer shall not use or disclose protected health information for any purpose other than in the performance of the health insurance issuer's functions, except as otherwise permitted by state or federal law, including providing such information to an independent review organization as required by this Part.

Acts 2013, No. 326, §1, eff. Jan. 1, 2015.