Uniform procedures for review and appeal for adverse

determinations.

A. A contracted entity shall utilize uniform procedures

established by the Authority under subsection B of this section for

the review and appeal of any adverse determination by the contracted

entity sought by any member or provider adversely affected by such

determination.

B. The Authority shall develop procedures for members or

providers to seek review by the contracted entity of any adverse

determination made by the contracted entity.

C. A provider shall have six (6) months from the receipt of a

claim denial to file an appeal.

D. A contracted entity shall ensure that all appeals of adverse

determinations made by the contracted entity are reviewed by a

licensed physician or, if appropriate for the requested service, a

licensed mental health professional. The contracted entity shall

not use any automated claim review software or other automated

functionality for such appeals.

E. The physician or mental health professional who reviews the

appeal shall:

1. Possess a current and valid unrestricted license in any

United States jurisdiction;

2. Be of the same or similar specialty as a physician or mental

health professional who typically manages the medical condition or

disease. This requirement shall be considered met:

a. for a physician, if:

(1) the physician maintains board certification for

the same or similar specialty as the medical

condition in question, or

(2) the physician’s training and experience:

(a) includes treatment of the condition,

(b) includes treatment of complications that may

result from the service or procedure, and

(c) is sufficient for the physician to determine

if the service or procedure is medically

necessary or clinically appropriate, or

b. for a mental health professional, if the mental health

professional’s training and experience:

(1) includes treatment of the condition, and

(2) is sufficient for the mental health professional

to determine if the service is medically

necessary or clinically appropriate;

3. Not have been directly involved in making the adverse

determination;

4. Not have any financial interest in the outcome of the

appeal; and

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5. Consider all known clinical aspects of the health care

service under review including, but not limited to, a review of any

medical records pertinent to the active condition that are provided

to the contracted entity by the member’s provider, or a health care

facility, and any pertinent medical literature provided to the

contracted entity by the provider.

F. Upon receipt of notice from the contracted entity that the

adverse determination has been upheld on appeal, the member or

provider may request a fair hearing from the Authority. The

Authority shall develop procedures for fair hearings in accordance

with 42 C.F.R., Part 431.