TITLE 23
Health and Safety

CHAPTER 23-17.12
Health Care Services – Utilization Review Act

SECTION 23-17.12-10


§ 23-17.12-10 External appeal requirements.

(a) In cases where the second level of appeal to reverse an adverse determination is unsuccessful, the review agent shall provide for an external appeal by an unrelated and objective appeal agency, selected by the director. The director shall promulgate rules and regulations including, but not limited to, criteria for designation, operation, policy, oversight, and termination of designation as an external appeal agency. The external appeal agency shall not be required to be certified under this chapter for activities conducted pursuant to its designation.

(b) The external appeal shall have the following characteristics:

(1) The external appeal review and decision shall be based on the medical necessity for the health care or service and the appropriateness of service delivery for which authorization has been denied.

(2) Neutral physicians, dentists, or other practitioners in the same or similar general specialty as typically manages the health care service shall be utilized to make the external appeal decisions.

(3) Neutral physicians, dentists, or other practitioners shall be selected from lists:

(i) Mutually agreed upon by the provider associations, insurers, and the purchasers of health services; and

(ii) Used during a twelve (12) month period as the source of names for neutral physician, dentist, or other practitioner reviewers.

(4) The neutral physician, dentist, or other practitioner may confer either directly with the review agent and provider, or with physicians or dentists appointed to represent them.

(5) Payment for the appeal fee charged by the neutral physician, dentist, or other practitioner shall be shared equally between the two (2) parties to the appeal; provided, however, that if the decision of the utilization review agent is overturned, the appealing party shall be reimbursed by the utilization review agent for their share of the appeal fee paid under this subsection.

(6) The decision of the external appeal agency shall be binding; however, any person who is aggrieved by a final decision of the external appeal agency is entitled to judicial review in a court of competent jurisdiction.

History of Section.
(P.L. 1992, ch. 398, § 1; P.L. 1999, ch. 222, § 1; P.L. 1999, ch. 512, § 1; P.L. 2005, ch. 184, § 1; P.L. 2005, ch. 238, § 1.)