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2011 SESSION

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HB 1928 Health insurance; independent external reviews.

Introduced by: Daniel W. Marshall, III | all patrons    ...    notes | add to my profiles

SUMMARY AS PASSED HOUSE: (all summaries)

Health insurance; independent external reviews. Revises the process for independent external reviews of a health carrier's adverse decision regarding covered health care benefits. The measure (i) eliminates the minimum eligibility threshold, (ii) eliminates the $50 filing fee, and (iii) expands situations for which an independent external review may be requested to include covered persons of all licensed health carriers. Currently, only persons covered by managed care health insurance programs may request an independent external review. Under this measure, insurers are required to incur the full cost of every review; currently, the Commonwealth incurs the cost of any review that does not result in denied services being covered. The measure tracks the Uniform Health Carrier External Review Model Act prepared by the National Association of Insurance Commissioners. The federal Patient Protection and Affordable Care Act requires states to adopt such an external review program by July 1, 2011. The measure also requires health carriers to establish an internal appeals process. The utilization review standards are revised to apply to adverse determinations, which are defined as determinations by a managed care health insurance plan that a request for benefit does not meet the plan's requirements or is determined to be experimental or investigational, thereby resulting in a denial, reduction, or termination of the requested benefit. The length of time the utilization review entity is required to maintain records is increased from five to six years. The measure expires July 1, 2014.


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