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1999 SESSION

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HB 2587 Review of adverse health utilization review decisions.

Introduced by: John H. Rust, Jr. | all patrons    ...    notes | add to my profiles

SUMMARY AS INTRODUCED:

Review of adverse utilization review decisions; review of claims appeal by an independent external panel. Establishes a process of independent external review for individuals denied a course of treatment by their managed care health plan. If the person seeking review is determined by the Health Commissioner or his designee (i) to have coverage by the health plan, (ii) to be seeking a treatment that appears to be covered by the plan, (iii) to have exhausted all available utilization review complaint and appeals procedures and (iv) to have provided all information necessary to begin review, an impartial health entity which is not related to or associated with the health plan being reviewed shall review the case. The Health Commissioner will, after reviewing the decision, issue a binding order affirming, modifying or reversing the decision of the health plan, based on a majority decision of the impartial health entity performing the review. The Board of Health will also promulgate regulations establishing (i) expedited appeals procedures for emergency situations, (ii) criteria and standards for eligible impartial health entities, and (iii) a schedule of fees to be paid by health plans upon conclusion of review. The bill also creates the Health Care Regulatory Fund, comprised of sums (i) appropriated from the General Assembly, (ii) health care regulatory assessments , (iii) income from the investment of moneys held by the Fund, and (iv) any other sums designated for deposit to the fund. The Health Commissioner will impose and collect from each managed care health insurance plan an assessment designed to fund the implementation of the review process created by this bill.


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