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H.R.4577
Departments of Labor, Health and Human Services, and Education, and
Related Agencies Appropriations Act, 2001 (Public Print)
`SEC. 503B. INDEPENDENT EXTERNAL APPEALS PROCEDURES FOR GROUP HEALTH
PLANS.
`(a) RIGHT TO EXTERNAL APPEAL- A group health plan, and a health
insurance issuer offering health insurance coverage in connection with a group
health plan, shall provide in accordance with this section participants and
beneficiaries (or authorized representatives) with access to an independent
external review for any denial of a claim for benefits.
`(b) INITIATION OF THE INDEPENDENT EXTERNAL REVIEW PROCESS-
`(1) TIME TO FILE- A request for an independent external review
under this section shall be filed with the plan or issuer not later than 60
business days after the date on which the participant or beneficiary
receives notice of the denial under section 503A(b)(4) or the date on which
the internal review is waived by the plan or issuer under section
503A(b)(1)(D).
`(A) IN GENERAL- Subject to the succeeding provisions of this
subsection, a group health plan, and a health insurance issuer offering
health insurance coverage in connection with a group health plan,
may--
`(i) except as provided in subparagraph (B)(i), require that a
request for review be in writing;
`(ii) limit the filing of such a request to the participant or
beneficiary involved (or an authorized representative);
`(iii) except if waived by the plan or issuer under section
503A(b)(1)(D), condition access to an independent external review under
this section upon a final determination of a denial of a claim for
benefits under the internal review procedure under section
503A;
`(iv) except as provided in subparagraph (B)(ii), require
payment of a filing fee to the plan or issuer of a sum that does not
exceed $50; and
`(v) require that a request for review include the consent of
the participant or beneficiary (or authorized representative) for the
release of medical information or records of the participant or
beneficiary to the qualified external review entity for purposes of
conducting external review activities.
`(B) REQUIREMENTS AND EXCEPTION RELATING TO GENERAL RULE-
`(i) ORAL REQUESTS PERMITTED IN EXPEDITED OR CONCURRENT CASES-
In the case of an expedited or concurrent external review as provided
for under subsection (e), the request may be made orally. In such case a
written confirmation of such request shall be made in a timely manner.
Such written confirmation shall be treated as a consent for purposes of
subparagraph (A)(v).
`(ii) EXCEPTION TO FILING FEE REQUIREMENT-
`(I) INDIGENCY- Payment of a filing fee shall not be required
under subparagraph (A)(iv) where there is a certification (in a form
and manner specified in guidelines established by the Secretary) that
the participant or beneficiary is indigent (as defined in such
guidelines). In establishing guidelines under this subclause, the
Secretary shall ensure that the guidelines relating to indigency are
consistent with the poverty guidelines used by the Secretary of Health
and Human Services under title XIX of the Social Security
Act.
`(II) FEE NOT REQUIRED- Payment of a filing fee shall not be
required under subparagraph (A)(iv) if the plan or issuer waives the
internal appeals process under section
503A(b)(1)(D).
`(III) REFUNDING OF FEE- The filing fee paid under
subparagraph (A)(iv) shall be refunded if the determination under the
independent external review is to reverse the denial which is the
subject of the review.
`(IV) INCREASE IN AMOUNT- The amount referred to in subclause
(I) shall be increased or decreased, for each calendar year that ends
after December 31, 2001, by the same percentage as the percentage by
which the Consumer Price Index for All Urban Consumers (United States
city average), published by the Bureau of Labor Statistics, for
September of the preceding calendar year has increased or decreased
from the such Index for September of 2001.
`(c) REFERRAL TO QUALIFIED EXTERNAL REVIEW ENTITY UPON REQUEST-
`(1) IN GENERAL- Upon the filing of a request for independent
external review with the group health plan, or health insurance issuer
offering coverage in connection with a group health plan, the plan or issuer
shall refer such request to a qualified external review entity selected in
accordance with this section.
`(2) ACCESS TO PLAN OR ISSUER AND HEALTH PROFESSIONAL INFORMATION-
With respect to an independent external review conducted under this section,
the participant or beneficiary (or authorized representative), the plan or
issuer, and the treating health care professional (if any) shall provide the
external review entity with access to information that is necessary to
conduct a review under this section, as determined by the entity, not later
than 5 business days after the date on which a request is referred to the
qualified external review entity under paragraph (1), or earlier as
determined appropriate by the entity to meet the applicable timelines under
clauses (ii) and (iii) of subsection (e)(1)(A).
`(3) SCREENING OF REQUESTS BY QUALIFIED EXTERNAL REVIEW ENTITIES-
`(A) IN GENERAL- With respect to a request referred to a qualified
external review entity under paragraph (1) relating to a denial of a claim
for benefits, the entity shall refer such request for the conduct of an
independent medical review unless the entity determines
that--
`(i) any of the conditions described in subsection (b)(2)(A)
have not been met;
`(ii) the thresholds described in subparagraph (B) have not been
met;
`(iii) the denial of the claim for benefits does not involve a
medically reviewable decision under subsection (d)(2);
`(iv) the denial of the claim for benefits relates to a decision
regarding whether an individual is a participant or beneficiary who is
enrolled under the terms of the plan or coverage (including the
applicability of any waiting period under the plan or coverage);
or
`(v) the denial of the claim for benefits is a decision as to
the application of cost-sharing requirements or the application of a
specific exclusion or express limitation on the amount, duration, or
scope of coverage of items or services under the terms and conditions of
the plan or coverage unless the decision is a denial described in
subsection (d)(2)(C);
Upon making a determination that any of clauses (i) through (v)
applies with respect to the request, the entity shall determine that the
denial of a claim for benefits involved is not eligible for independent
medical review under subsection (d), and shall provide notice in
accordance with subparagraph (D).
`(i) IN GENERAL- The thresholds described in this subparagraph
are that--
`(I) the total amount payable under the plan or coverage for
the item or service that was the subject of such denial exceeds a
significant financial threshold (as determined under guidelines
established by the Secretary); or
`(II) a physician has asserted in writing that there is a
significant risk of placing the life, health, or development of the
participant or beneficiary in jeopardy if the denial of the claim for
benefits is sustained.
`(ii) THRESHOLDS NOT APPLIED- The thresholds described in this
subparagraph shall not apply if the plan or issuer involved waives the
internal appeals process with respect to the denial of a claim for
benefits involved under section 503A(b)(1)(D).
`(C) PROCESS FOR MAKING DETERMINATIONS-
`(i) NO DEFERENCE TO PRIOR DETERMINATIONS- In making
determinations under subparagraph (A), there shall be no deference given
to determinations made by the plan or issuer under section 503A or the
recommendation of a treating health care professional (if
any).
`(ii) USE OF APPROPRIATE PERSONNEL- A qualified external review
entity shall use appropriately qualified personnel to make
determinations under this section.
`(D) NOTICES AND GENERAL TIMELINES FOR DETERMINATION-
`(i) NOTICE IN CASE OF DENIAL OF REFERRAL- If the entity under
this paragraph does not make a referral to an independent medical
reviewer, the entity shall provide notice to the plan or issuer, the
participant or beneficiary (or authorized representative) filing the
request, and the treating health care professional (if any) that the
denial is not subject to independent medical review. Such
notice--
`(I) shall be written (and, in addition, may be provided
orally) in a manner calculated to be understood by an average
participant;
`(II) shall include the reasons for the determination;
and
`(III) include any relevant terms and conditions of the plan
or coverage.
`(ii) GENERAL TIMELINE FOR DETERMINATIONS- Upon receipt of
information under paragraph (2), the qualified external review entity,
and if required the independent medical reviewer, shall make a
determination within the overall timeline that is applicable to the case
under review as described in subsection (e), except that if the entity
determines that a referral to an independent medical reviewer is not
required, the entity shall provide notice of such determination to the
participant or beneficiary (or authorized representative) within 2
business days of such determination.
`(d) INDEPENDENT MEDICAL REVIEW-
`(1) IN GENERAL- If a qualified external review entity determines
under subsection (c) that a denial of a claim for benefits is eligible for
independent medical review, the entity shall refer the denial involved to an
independent medical reviewer for the conduct of an independent medical
review under this subsection.
`(2) MEDICALLY REVIEWABLE DECISIONS- A denial described in this
paragraph is one for which the item or service that is the subject of the
denial would be a covered benefit under the terms and conditions of the plan
or coverage but for one (or more) of the following
determinations:
`(A) DENIALS BASED ON MEDICAL NECESSITY AND APPROPRIATENESS- The
basis of the determination is that the item or service is not medically
necessary and appropriate.
`(B) DENIALS BASED ON EXPERIMENTAL OR INVESTIGATIONAL TREATMENT-
The basis of the determination is that the item or service is experimental
or investigational.
`(C) DENIALS OTHERWISE BASED ON AN EVALUATION OF MEDICAL FACTS- A
determination that the item or service or condition is not covered but an
evaluation of the medical facts by a health care professional in the
specific case involved is necessary to determine whether the item or
service or condition is required to be provided under the terms and
conditions of the plan or coverage.
`(3) INDEPENDENT MEDICAL REVIEW DETERMINATION-
`(A) IN GENERAL- An independent medical reviewer under this
section shall make a new independent determination with respect
to--
`(i) whether the item or service or condition that is the
subject of the denial is covered under the terms and conditions of the
plan or coverage; and
`(ii) based upon an affirmative determination under clause (i),
whether or not the denial of a claim for a benefit that is the subject
of the review should be upheld or reversed.
`(B) STANDARD FOR DETERMINATION- The independent medical
reviewer's determination relating to the medical necessity and
appropriateness, or the experimental or investigation nature, or the
evaluation of the medical facts of the item, service, or condition shall
be based on the medical condition of the participant or beneficiary
(including the medical records of the participant or beneficiary) and the
valid, relevant scientific evidence and clinical evidence, including
peer-reviewed medical literature or findings and including expert
consensus.
`(C) NO COVERAGE FOR EXCLUDED BENEFITS- Nothing in this subsection
shall be construed to permit an independent medical reviewer to require
that a group health plan, or health insurance issuer offering health
insurance coverage in connection with a group health plan, provide
coverage for items or services that are specifically excluded or expressly
limited under the plan or coverage and that are not covered regardless of
any determination relating to medical necessity and appropriateness,
experimental or investigational nature of the treatment, or an evaluation
of the medical facts in the case involved.
`(D) EVIDENCE AND INFORMATION TO BE USED IN MEDICAL REVIEWS- In
making a determination under this subsection, the independent medical
reviewer shall also consider appropriate and available evidence and
information, including the following:
`(i) The determination made by the plan or issuer with respect
to the claim upon internal review and the evidence or guidelines used by
the plan or issuer in reaching such determination.
`(ii) The recommendation of the treating health care
professional and the evidence, guidelines, and rationale used by the
treating health care professional in reaching such
recommendation.
`(iii) Additional evidence or information obtained by the
reviewer or submitted by the plan, issuer, participant or beneficiary
(or an authorized representative), or treating health care
professional.
`(iv) The plan or coverage document.
`(E) INDEPENDENT DETERMINATION- In making the determination, the
independent medical reviewer shall--
`(i) consider the claim under review without deference to the
determinations made by the plan or issuer under section 503A or the
recommendation of the treating health care professional (if
any);
`(ii) consider, but not be bound by the definition used by the
plan or issuer of `medically necessary and appropriate', or
`experimental or investigational', or other equivalent terms that are
used by the plan or issuer to describe medical necessity and
appropriateness or experimental or investigational nature of the
treatment; and
`(iii) notwithstanding clause (ii), adhere to the definition
used by the plan or issuer of `medically necessary and appropriate', or
`experimental or investigational' if such definition is the same as the
definition of such term--
`(I) that has been adopted pursuant to a State statute or
regulation; or
`(II) that is used for purposes of the program established
under titles XVIII or XIX of the Social Security Act or under chapter
89 of title 5, United States Code.
`(F) DETERMINATION OF INDEPENDENT MEDICAL REVIEWER- An independent
medical reviewer shall, in accordance with the deadlines described in
subsection (e), prepare a written determination to uphold or reverse the
denial under review. Such written determination shall include the specific
reasons of the reviewer for such determination, including a summary of the
clinical or scientific-evidence based rationale used in making the
determination. The reviewer may provide the plan or issuer and the
treating health care professional with additional recommendations in
connection with such a determination, but any such recommendations shall
not be treated as part of the determination.
`(e) TIMELINES AND NOTIFICATIONS-
`(1) TIMELINES FOR INDEPENDENT MEDICAL REVIEW-
`(A) PRIOR AUTHORIZATION DETERMINATION-
`(i) IN GENERAL- The independent medical reviewer (or reviewers)
shall make a determination on a denial of a claim for benefits that is
referred to the reviewer under subsection (c)(3) not later than 14
business days after the receipt of information under subsection (c)(2)
if the review involves a prior authorization of items or
services.
`(ii) EXPEDITED DETERMINATION- Notwithstanding clause (i), the
independent medical reviewer (or reviewers) shall make an expedited
determination on a denial of a claim for benefits described in clause
(i), when a request for such an expedited determination is made by a
participant or beneficiary (or authorized representative) at any time
during the process for making a determination, and the treating health
care professional substantiates, with the request, that a determination
under the timeline described in clause (i) would seriously jeopardize
the life or health of the participant or beneficiary. Such determination
shall be made not later than 72 hours after the receipt of information
under subsection (c)(2).
`(iii) CONCURRENT DETERMINATION- Notwithstanding clause (i), a
review described in such subclause shall be completed not later than 24
hours after the receipt of information under subsection (c)(2) if the
review involves a discontinuation of inpatient care.
`(B) RETROSPECTIVE DETERMINATION- The independent medical reviewer
(or reviewers) shall complete a review in the case of a retrospective
determination on an appeal of a denial of a claim for benefits that is
referred to the reviewer under subsection (c)(3) not later than 30
business days after the receipt of information under subsection
(c)(2).
`(2) NOTIFICATION OF DETERMINATION- The external review entity shall
ensure that the plan or issuer, the participant or beneficiary (or
authorized representative) and the treating health care professional (if
any) receives a copy of the written determination of the independent medical
reviewer prepared under subsection (d)(3)(F). Nothing in this paragraph
shall be construed as preventing an entity or reviewer from providing an
initial oral notice of the reviewer's determination.
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